Aneurysmal subarachnoid hemorrhage for craniotomy and clipping
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The stem
A 49-year-old woman, 64 kg, collapsed at work 11 hours ago with a sudden severe headache. She is drowsy but opens her eyes to voice, is oriented, and has mild right arm weakness (Hunt-Hess grade III). CT shows thick subarachnoid blood in the left Sylvian fissure, and angiography shows a 9 mm wide-necked left middle cerebral artery bifurcation aneurysm; the neurovascular team has chosen craniotomy and clipping over coiling. An external ventricular drain was placed on arrival. She has hypertension and smokes. Medications: lisinopril, nimodipine 60 mg every 4 hours via nasogastric tube since admission. Allergies: none known.
- Blood pressure 176/98 mmHg, heart rate 58, SpO2 97% on 2 L nasal cannula
- ICP 18 mmHg; ventricular drain currently clamped (set at 15 cmH2O when open)
- Sodium 133 mEq/L, potassium 3.6, glucose 172 mg/dL, hemoglobin 13.1 g/dL
- High-sensitivity troponin 310 ng/L
- ECG: sinus bradycardia, deep symmetric T-wave inversion V2–V6, QTc 520 ms
- Echocardiogram: ejection fraction 45%, apical and mid-wall hypokinesis not matching one coronary territory