Subarachnoid Hemorrhage

A 48-year-old right-handed male presented to the emergency department (ED) with chief complaint of headache of 8 h duration, which was sudden in onset, severe from the onset, and progressively increasing in intensity, diffuse, non-radiating, without any aggravating or relieving factors, associated with multiple episodes of projectile non-bilious vomiting. The patient doesn’t give a history of loss of consciousness and abnormal body movements. There was no history of head trauma or similar attacks in the past. There was no history of fever, burning micturition, palpitation, chest pain, or heaviness. He is a known case of hypertension for 12 years under regular medication of losartan 50 mg once a day. He is also a known case of type 2 diabetes mellitus for the last 10 years for which he is taking metformin. He occasionally consumes homemade alcohol and smokes cigarettes, around 10 packs per year for the last 20 years. On examination in ED, he was well oriented to time, place, and person with the Glasgow Coma Scale (GCS) of 15. His vital parameters were stable. His neurological examination was within normal limits, and other systemic examinations did not reveal any abnormalities. He underwent a plain CT head, which showed diffuse subarachnoid hemorrhage (SAH) more on the left sylvian fissure. He subsequently underwent cerebral CT angiography (CTA), which showed a bilateral middle cerebral artery (MCA) aneurysm. The provisional diagnosis of spontaneous SAH due to bilateral MCA aneurysm rupture with the World Federation of Neurological Surgeons (WFNS) grade-1 was made, and he was posted for the surgery as a semi-emergency case. He underwent left pterional craniotomy and microsurgical clipping of the aneurysm. The immediate post-operative period was uneventful. On the second post-operative day, he became drowsy and developed hemiparesis of right half of the body. Transcranial Doppler study showed features of vasospasm. He was then managed with blood pressure (BP) augmentation therapy, maintaining the normal central venous pressure (CVP). Over the next 6 h of treatment, there was a gradual improvement in his level of consciousness and hemiparesis. He was shifted to the ward on the fourth post-operative day and was discharged from hospital on the seventh post-operative day with the GCS of 15 and no focal neurological deficits with advice for endovascular coiling of the right-sided aneurysm at a later date.