Medical Image of the Week: Subarachnoid Hemorrhage

Figure 1. Axial CT of the head without contrast demonstrates a large subarachnoid hemorrhage in the basal cisterns and adjacent to the insular cortices (blue arrows).

Figure 2. Coronal CT angiogram of the head demonstrates a saccular outpouching of the anterior communicating artery (blue arrow) consistent with an aneurysm.

A 70-year-old lady with a past medical history of hypertension and dyslipidemia was brought in by her family members for evaluation of confusion and headache for 1 week. There was no history of recent trauma or falls. There was no known family history of aneurysm or sudden death. On examination, her blood pressure was 139/99 mmHg, heart rate 92 bpm, afebrile and respiratory rate was 13 breaths per minute. She was alert but only oriented to self. Pupils were symmetric and reactive to light. She was able to follow commands and power was symmetric in all limbs.

CT of the head without contrast showed diffuse subarachnoid and intraventricular hemorrhage with signs of raised intracranial pressure (Figure 1). Neurosurgery was consulted and she underwent emergent insertion of an external ventricular drain. Head CT post-ventriculostomy showed improvement in her ventricular dilatation. CT angiography was performed later and showed an anterior communicating artery aneurysm (Figure 2), thought to be culprit of her subarachnoid hemorrhage. Craniotomy with surgical clipping was performed. This was followed by improvement in her mental status.

The common presenting symptom of patients with subarachnoid hemorrhage is headache. They will classically describe it as "worst headache of my life". This can be accompanied by altered mental status, nausea, vomiting, or meningeal signs. Head CT without contrast should be obtained immediately if there is suspicion of subarachnoid hemorrhage. Studies have shown that head CT is extremely sensitive if obtained within 6 hours of clinical presentation but its sensitivity declines over time (1). Lumbar puncture should be performed if head CT is negative but there is strong suspicion of subarachnoid hemorrhage. A combination of negative head CT and lumbar puncture is sufficient to rule out subarachnoid hemorrhage in a patient presented with headache (2).

Kai Rou Tey¹, MD; Tammer Elaini², MD

¹Department of Internal Medicine, University of Arizona College of Medicine- South Campus and ²Department of Pulmonary, Critical Care, Allergy and Sleep University of Arizona College of Medicine

Tucson, AZ USA

References

1. Perry JJ, Stiell IG, Sivilotti ML, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ. 2011;343:d4277. [CrossRef] [PubMed]
2. Perry JJ, Spacek A, Forbes M, et al. Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage? Ann Emerg Med. 2008 Jun;51(6):707-13. [CrossRef] [PubMed] 

Cite as: Tey KR, Elaini T. Medical image of the week: subarachnoid hemorrhage. Southwest J Pulm Crit Care. 2016;13(2):88-9. doi: http://dx.doi.org/10.13175/swjpcc063-16 PDF

Medical Image of the Week: Neurogenic Pulmonary Edema

Figure 1. CT scan showing intraparenchymal hemorrhage in the left frontal lobe, scattered subdural, subarachnoid and intraventricular hemorrhage with 1.1 cm of left to right midline shift.

Figure 2. Chest X-ray showing central vascular congestion with bilateral pulmonary edema throughout the lung fields

A 79 year old woman with a history of diabetes, hypertension and subarachnoid hemorrhage presented to the emergency department (ED) with altered mental status. The patient had a fall one day prior to admission, and hit her head on the ground. There was no loss of consciousness or seizure activity at that moment, however, she was found unresponsive in the bathroom the next day with brownish vomitus in the mouth and on her face. CT of the head without contrast showed a large intraparenchymal hemorrhage on the left frontal lobe with subdural hemorrhage on the right frontal and temporal lobe. Also, intraventricular blood with 1.1 cm left to right midline shift was observed (Figure 1). Although she had no history of left heart failure or pulmonary disease, physical exam showed coarse lung sound and chest X-ray showed acute change with prominence central vasculature with fluffy central airspace opacities, which were consistent with neurogenic pulmonary edema secondary to intracranial hemorrhage (Figure 2). An external ventricular drain was placed by neurosurgery and patient was intubated for airway protection, however she passed away the next day after her family decided comfort care.

The most common cause of neurogenic pulmonary edema is central nervous system injury including cerebral hemorrhage, head trauma and epileptic seizure (1). It usually develops several hours after an insult, although cases of immediate or delayed onset have been reported. The most common symptoms and signs include dyspnea, hemoptysis, tachypnea, tachycardia, which are not secondary to heart or lung parenchymal disease. Aspiration pneumonia is common presentation of patients with altered mental status, and it is hard to differentiate neurogenic pulmonary edema from aspiration pneumonia, however neurogenic pulmonary edema tends to develop and resolve more rapidly with no signs of infection such as fever and focal infiltration (2). The prognosis of neurogenic pulmonary edema mainly depends on the neurologic pathology rather than pulmonary edema itself, and the mainstream of treatment is supportive care, although medications including β-agonists, dobutamine or chlorpromazine can be tried.

Seongseok Yun, MD PhD; Tuan Phan, MD; Natasha Sharda, MD

Department of Medicine, University of Arizona, Tucson, AZ 85724, USA

References

1. Neurogenic pulmonary oedema. Lancet. 1985;1(8443):1430-1. [PubMed]
2. Colice GL, Matthay MA, Bass E, Matthay RA. Neurogenic pulmonary edema. Am Rev Respir Dis. 1984;130(5):941-8. [PubMed] 

Reference as: Yun S, Phan T, Sharda N. Medical image of the week: neurogenic pulmonary edema. Southwest J Pulm Crit Care. 2014;8(1): . doi: http://dx.doi.org/10.13175/swjpcc004-14 PDF