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Chief Complaint: Headache, nausea, and weakness. History of Present Illness: 67 year old RH man with a history of CHF, HTN, hyperlipidemia, atrial fibrillation on warfarin, and CAD s/p CABG on aspirin and plavix admitted for subdural hemorrhage. On 9/16, patient presented to Palisade Hospital at 10am with sudden onset headache, nausea, and right sided weakness. According to ER notes, his son stated there may have been a fight the day before at home but wife denies this. Patient had ecchymoses on his left arm and upper thigh but no scalp hematoma. His neurological exam was significant for lethargy, dysarthria, right hemiparesis, and Babinski sign on the right. Head CT showed a large left subdural hematoma with 18mm of midline shift. He was given mannitol 50mg, vitamin K 10mg, and FFP. He was intubated and transferred to the NICU at noon.
Hospital Course: On exam under propofol, patient did not respond to command, open his eyes, or blink to threat; his pupils were reactive; there were no eye movements with oculocephalic maneuvre; corneal reflex was present; and he was withdrawing bilaterally, left more than right. He was given vitamin K 10mg, DDAVP 24mg, FFP, and platelets, and taken to the OR for emergency decompression. After surgery, he developed spontaneous hemorrhages in the cerebellum and left frontal lobe. Patient continues to have atrial fibrillation throughout his hospital course. On 9/17, his PT was 19.2, PTT 32.4, and INR 1.55. Tracheostomy cuff was changed on 9/30. Sputum culture on 9/29 showed klebsiella pneumoniae and patient was started on piperacillin tazobactam, tobramycin, and vancomycin. Patient continues to have tremor in his head, left arm and leg. cEEG on 9/30 showed no ictal rhythm associated with the tremor. Patient was alert and able to follow commands yesterday.
Past Medical History: CHF, HTN, hyperlipidemia, atrial fibrillation on warfarin, CAD s/p CABG in 1999 on aspirin and plavix.
Past Surgical History: left hemicraniectomy, external ventricular drain, PEG placement, tracheostomy.
Family History: Noncontributory.
Social History: Patient is fully functional and lives with his wife. Denies smoking, alcohol, or drug use.
Lisinopril 20mg PO daily
Hctz 25mg PO daily
Coumadin 4mg PO daily
Lipitor 20mg PO daily
Amlodipine 10mg PO daily
Digoxin 125mg PO daily
Metoprolol 25mg PO daily
Plavix 75mg OP daily
Protonix 40mg PO daily
Aspirin 81mg PO daily
Piperacillin Tazobactam Inj +R+ 4.5 G IVPB q8hr
Tobramycin Inj 500 MG IVPB q24h
Vancomycin IVPB **INITIAL-72 HR STOP** 1250 mg IVPB q12hr (completed)
Digoxin Load Oral Liq 100 microgram PO q24h
Furosemide Oral Liq 40 MG PER PEG q12hr
Lisinopril Oral 20 MG PO q24h
Metoprolol Tartrate Oral 50 mg PO q6hr
Ipratropium Bromide Inh Soln 2.5 ML INHALATION q6hr
Escitalopram Oral 10 mg PO q24h
Fentanyl Patch 12 microgram TRANSDERM q72h
Levetiracetam Oral Liq 500 mg PO q12hr
Enoxaparin Inj 40 MG SUBQ daily 9am
Docusate Sodium Oral Liq 100 MG PER PEG tid-(9,13,17)
Esomeprazole Oral Liq 40 mg PO daily 9am
Multivitamin Oral Liq 5 ML PER NG bedtime
Senna Oral Liq 10 ML PER NG daily 9am
Acetylcysteine 20% Inh Soln 3 ml INHALATION q12hr
Chlorhexidine Gluconate Oral Soln 15 ml SWAB q12hr
free water 250 cc PER PEG q6hr
Nystatin Topical Powder 1 APPLIC TOP q8hr
Acetaminophen Oral 650 mg PO q4h
Acetaminophen Rectal 650 MG RECTAL q6hr
Oxycodone Immediate Release Oral 5 MG PER PEG q4h
Oxycodone Immediate Release Oral 10 MG PER PEG q4h
Fleet Enema Adult Rectal 1 UNIT RECTAL Once
Allergies: Cefazolin induces hives..
VITALS (last 24h):
Tc: 37.9 Tmax: 38.4 @ 02 Oct 20:00
HR: 86 (80 - 116)
BP: 136/90 (131/77 - 156/99)
Mode: Vol Contl, FiO2: 40, SpO2: 98% (92 - 98), RR(set): 12, VT(set): 550, VT(exhaled): 575, MV(exhaled): 9.5, PEEP: 5
General: Lying in bed with tremor in left arm and leg.
HEENT: Tracheostomy site clean and dry.
Skin: No rashes.
Cardiac: Irregularly irregular rhythm. Normal S1 and S2. No carotid bruits.
Pulmonary: Lungs clear to auscultation.
Abdomen: Normal bowel sounds. Not distended and no masses. PEG site clean and dry.
Extremities: 3+ bilateral pitting edema. 3+ biceps, radial, dorsalis pedis pulses. 0+ popliteal and posterior tibial pulses.
GU: Urinating via texas catheter.
MSE: Opens eyes in response to verbal command and spontaneously. Can stick out tongue on command but does not respond to other commands. Cannot answer questions verbally. Tracks movement with eyes.
Cranial nerves: PERRLA 3->2.5mm. Tongue protrudes symmetrically.
Motor: Normal bulk. Flaccid extremities on right. Normal tone on left. No resistance to fall on either arm. Moves left upper arm spontaneously but not other limbs.
Sensory: Extremities withdraw to pain.
Reflexes: 2+ biceps, triceps, brachioradialis, patellar, and Achilles tendon reflexes bilaterally. No clonus or Babinski signs.
Coordination: Not tested.
Gait: Not tested.
LABS (last 24h):
145 | 102 | 36
--------------------< 135 Ca: 8.2 P: 4.6 Mg: 2.3 [10/03 @ 05:00]
4.2 | 28 | 2.2
WBC: 14.1 / Hb: 8.6 / Hct: 30.3 / Plt: 314 [10/03 @ 05:00]
MRI brain (9/22): Persistent bilateral extra axial collections left larger than right, left associated with postop changes and some minimal mass effect no midline shift the ventricular size is unchanged since prior CT scan, small area of acute infarct in the left posterior frontal cortex
CT head (9/19): Interval minimal enlargement of the left frontal extra-axial collection underneath the bony flap as described when compared to the earlier scan otherwise ventricular size is stable. Increase in size of left frontal parenchymal hemorrhage with increased mass effect upon the left frontal horn and mild left-to-right midline shift.
CT head (9/19): Slight decrease in hydrocephalus, no change in bilateral cerebellar hemorrhages with persistent mass effect upon the fourth ventricle, new left frontal deep white matter parenchymal hemorrhage lateral to the left frontal horn
CT head (9/17): New interval slight inward displacement of the left craniotomy bone fragment, persistent bilateral cerebellar and left inferior frontal hemorrhages, stable, interval decrease in pneumocephalus, ventricular size is stable with persistent mild dilatation of the temporal horns, persistent tentorial hemorrhage, s/p drain placement, postsurgical changes with 8mm left-to-right midline shift secondary to left frontal lobe swelling
CT head immediately post-craniectomy (9/16): Diffuse cerebral swelling with effacement of the basal cisterns and fourth ventricle, thin residual left posterior interhemispheric subdural hemorrhage, without significant mass effect, no acute large infarct.
Neurophysiology: 9/30 cEEG:
1. Background: Continuous and reactive. 2. There was continuous focal slowing in the left hemisphere, maximal left temporal, mainly in the delta range. 3. No epileptiform discharges. 4. There were frequent periods of intermittent irregular leftward head jerking and left shoulder jerking. These were not associated with any definite ictal rhythm on EEG. 5. Sleep: State changes but no normal stage 2 sleep transients.
Echocardiogram: TTE: Very limited study, normal LV and RV size and function - clear regional wall motion abnormalities are not seen, significant valve disease is not seen, trace pericardial effusion.
Assessment: 67 year old man transferred from Palisade Hospital for left subdural hemorrhage while on anticoagulation and antiplatelet medications, s/p left hemicraniectomy with subsequent bilateral cerebellar and left frontal intraparenchymal hemorrhages, obstructive hydrocephalus s/p external ventricular drain, s/p tracheostomy and PEG placement, now with continued altered mental status including decreased alertness and attention.
Localization: At the time of initial presentation to Palisades Hospital, the patient's symptoms of headache, dysarthria, and lethargy suggested increased intracranial pressure. His right hemiparesis and right Babinski sign suggested a large, left sided lesion involving the motor cortex. Currently at CUMC, the patient's altered mental status suggests a CNS lesion. Paralysis of the patient's right arm and leg suggest a left frontal lobe lesion while paralysis of the left leg suggests a right frontal lobe lesion that is parafalcine. The one lesion that can explain both findings is an interhemispheric subdural hemorrhage.
Subdural hematoma (SDH) is a bleed into the subdural space between the dura mater and arachnoid mater. The most common causes are head trauma, cerebral atrophy, and antithrombotic therapy. In this case, the patient's SDH may have been caused by a combination of all three. First, there is a possible history of head trauma on the night prior to the onset of symptoms. Head trauma, such as falls, motor vehicle accidents, or assaults, can lead to rupture of the bridging veins that drain into the dural sinuses or the rupture of small cortical arteries (Gennarelli 1982). Second, given the patient's age, he is at increased risk for cerebral atrophy. Two other risk factors for cerebral atrophy, neither of which the patient has, are alcohol abuse and previous traumatic brain injury. Third, the patient was on the anticoagulant warfarin and the antiplatelet agents aspirin and plavix when his symptoms began. Studies have shown that antithrombotic agents increase the risk for SDH. Indeed, one study of patients with chronic SDH following head trauma showed that 21% had been on oral anticoagulants and 13% on aspirin at the time of hemorrhage (Reymond 1992).
This patient's SDH can be classified as acute based on the fact that he experienced rapid neurological decline within one to two days of onset of symptoms. Half of patients with acute SDH enter a coma at the time of injury. However, in 12-38 percent of cases, including this patient, there is a lucid interval following injury before the patient descends into a coma (McBride 2010). In addition to the history and physical exam findings outlined above, imaging is an important contributor to the diagnosis of SDH. The imaging modality used in this case was head CT, which has the advantages of speed and cost over brain MRI. On CT, SDH is visualized as a crescent shaped area of hyperdensity. However, brain MRI is more sensitive for SDH than CT, especially for interhemispheric SDH's as was the case in this patient.
An important management decision in acute SDH is whether to surgically evacuate the hematoma or manage it nonsurgically. Current recommendations propose that an acute SDH with a thickness of greater than 10mm or a midline shift greater than 5mm on CT should be surgically evacuated regardless of the patient's Glasgow Coma Scale score (Bullock 2010). Given that this patient had a severe midline shift of 18mm, surgery was the correct management choice. Surgical options include burr hole trephination and decompressive craniectomy. There is limited data to suggest that craniectomy produces superior outcomes to burr hole trephination (Chesnut 2006). The patient was rushed to the OR soon after admission because studies have shown that surgery performed within 2-4 hours after onset of symptoms produced lower morbidity and mortality compared to delayed surgeries (Haselsberger 1988).
In order for the surgery to take place, the patient's antiplatelet and anticoagulation medications were stopped and reversed. Current options for reversing anticoagulation include fresh frozen plasma, prothrombin complex concentrate (PCC), recombinant human factor VIIa and vitamin K. In this case, fresh frozen plasma and vitamin K were used because of their availability. However, PCC when available is recommended over FFP because it provides all of the vitamin-K dependent coagulation factors in a smaller volume (McBride 2010). DDAVP and platelets were also given to the patient to promote primary hemostasis. Intravenous mannitol was given to reduce the patient's elevated intracranial pressure.
1. Monitor neurological exam and repeat head CT to assess for hemorrhages or hydrocephalus.
2. Continue Keppra 500mg PO BID for seizure prophylaxis.
3. Continue PT/OT and assess for disposition to acute rehabilitation.
4. Neurosurgery is following regarding skull flap replacement.
5. Continue lexapro for depression treatment.
6. Oxycodone PRN and fentanyl patch for pain.
1. Lisinopril and furosemide to control blood pressure. Target SBP < 130.
2. Digoxin and metoprolol for rate control for atrial fibrillation.
1. Continue A/C ventilation.
2. Continue ipratropium and acetylcysteine.
1. PEG placed 9/28.
3. Senna and docusate.
1. Free water 250cc per PEG q6hr.
2. NS 1000ml IV 20ml/hr to correct elevated BUN.
1. Continue vancomycin, tobramycin, and zosyn (started 9/30) for klebsiella pneumonia.
2. Monitor Tobramycin and vancomycin trough.
3. Nystatin powder to left axilla.
4. Follow up blood and urine culture, C. difficile PCR.
5. Acetaminophen for fever.
1. DVT prophylaxis: Venodyne boots and lovenox.
2. Monitor INR. Goal <1.4.