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Management of aneurysmal subarachnoid hemorrhage
1Department of Neurology and Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA.
Neurologic Clinics
|August 1, 1995
Summary
This case highlights the critical importance of monitoring phenytoin levels in patients with subarachnoid hemorrhage to prevent seizures and neurological decline. Prompt recognition and management of vasospasm and drug toxicity are crucial for patient recovery.
Area of Science:
- Neurology
- Neurosurgery
- Critical Care Medicine
Background:
- Subarachnoid hemorrhage (SAH) management involves addressing vasospasm to prevent ischemic deficits.
- Treatment strategies include enhancing cardiac output, inducing hypertension, and expanding intravascular volume to improve cerebral blood flow (CBF).
- Emerging therapies include tPA, anti-inflammatory drugs, neuroprotective agents, and endovascular interventions.
Observation:
- A 63-year-old woman with SAH experienced neurological decline after ventriculostomy clamping.
- Initial CT scans showed no new hemorrhage or infarct, leading to suspicion of vasospasm.
- Further investigation revealed a critically low phenytoin level, suggesting a seizure and postictal state.
Findings:
- The patient's neurological status fluctuated, initially improving after aneurysm surgery but deteriorating later.
- Phenytoin toxicity was suspected due to a high level (5.5), followed by a postictal state.
- Cerebral angiography confirmed moderate to severe vasospasm in the anterior cerebral artery (ACA) and middle cerebral artery (MCA).
Implications:
- This case underscores the necessity of vigilant monitoring of anticonvulsant drug levels, such as phenytoin, in SAH patients.
- It emphasizes the differential diagnosis of neurological deterioration, including vasospasm, seizures, and drug toxicity.
- Effective management requires a multimodal approach addressing hemodynamic parameters, potential complications, and neuroprotection.