General Data

• I.B.• 54/M• Right-handed farmer• From Abra

• Transferred to our institution due to CT scan findings of subarachnoid hemorrhage

History of Present Illness

• 1 month PTA (3/14/2010)– (+) dizziness, (+) syncope, (+) severe headache,

VAS 10/10, (+) left-sided weakness– Brought to a local hospital (Abra Provincial

Hospital) and treated as a case of CVD– A CT scan done in Vigan ten days post-event

revealed subarachnoid hemorrhage and aneurysm

History of Present Illness

• 1 month PTA– At this point, (-) sensorial changes, (+) minimal

nape pain, (-) facial asymmetry– The patient was advised transfer to PGH for

further evaluation and surgery– Patient opted not to consult due to financial

constraints

History of Present Illness

• 2 weeks PTA– The patient was discharged asymptomatic after

two weeks

• 1 week PTA– The patient had sudden onset, persistent, piercing

headache, (-) radiations, VAS 10/10, patient made no note of relieving or aggravating factors, (-) medications taken

History of Present Illness

• 1 week PTA– Consulted again in Abra Provincial hospital,

admitted for three days, given unrecalled medications with some pain relief

– Patient opted to take physician’s advice to seek consult in our institution

Past Medical History

• (-) previous diagnosis of HPN, but with note of hypertensive episodes on casual checking of blood pressure; no consults done

• (-) DM / PTB / BA / allergies

Family Medical History

• (+) HPN – siblings• (-) DM / PTB / BA / allergies

Personal/Social History

• (-) smoking• (-) alcoholic beverage consumption• (-) illicit drug use• Married with 6 stepchildren, 3 biological

children

Review of Systems

• (-) fever• (-) cough• (-) colds• (-) DOB• (-) abdominal pain• (-) bowel changes• (-) dysuria

• (-) jaundice• (-) weight loss• (-) tinnitus• (-) blurring of vision• (-) rash• (-) orthopnea• (-) easy fatigability

Physical Examination

• Conscious, coherent, not in distress• Vitals: 130/80 100 20 36.7oC

• HEENT: pink conjunctivae, anicteric sclerae, (-) cervical lymphadenopathy, (-) masses, (-) nystagmus

• Chest/Lungs: equal chest expansion, clear breath sounds, (-) rales/wheezes

Physical Examination

• CVS: (-) heaves/thrills, distinct heart sounds, normal rate, regular rhythm, (-) murmurs

• Abdomen: soft, flat, nontender, normoactive bowel sounds, (-) masses/organomegaly

• Extremities: pink nail beds, full equal pulses, (-) cyanosis/edema

Neurologic Examination

• Awake, coherent, oriented• E4V5M6

• Cranial Nerves– I – not assessed– II – pupils 3cm briskly reactive to light– III, IV, VI – full, equal EOM’s– V – intact V1-3, brisk corneals

– VII – (+) facial asymmetry; shallow R nasolabial fold

Neurologic Examination

• Cranial Nerves– VIII – intact gross hearing– IX, X – intact gag, uvula midline– XI – good shoulder shrug– XII – tongue midline

• Good muscle tone• Motor strength 5/5 on all extremities

Neurologic Examination

• 100% sensation on all extremities• DTR’s ++• (-) Babinski reflex• (-) clonus

Course in the Wards

Course in the Wards

Course in the Wards

Laboratory Results

• Blood Type: A+• CBC– 4/23/10: Hgb 163, Hct 0.458, WBC 5.8, Plt 266, L

0.615, N 0.263– 4/27/10: Hgb 115, Hct 0.321, WBC 9.41, Plt 248, L

0.878, N 0.079

Laboratory Results

• PT/ PTT (4/23/10)– PT: 11.5/10.5/>1.0/1.01– aPTT: 34.7/34.4

• Blood Chemistry– 4/23/10: Glu 6.01, BUN 11.58, Crea 69, Na 132, K

3.7, Cl 90– 4/26/10: BUN 3.99, Crea 52, Na 196, K 3.4, Cl 112

Laboratory Results

• U/A– 4/24/10: yellow, turbid, pH 8.0, Sp Gr 1.010, CHO

(-), CHON (-), RBC 9, WBC 2, EC 2, Cast 0, Crystals 0, Bac 17

Summary

• 54 y/o male• Apparently well until he presented with

headache and left-sided weakness• Initially managed as a case of CVD, but with

findings of subarachnoid hemorrhage on CT scan done 10 days post event

Summary

• 4- vessel angiogram showed – Saccular aneurysm, L anterior cerebral artery-

anerior communicating artery junction site, with light vasospasm

– Aplastic A1 segment, R anterior cerebral artery, patent anterior communicating artery

Four-Vessel Angiogram• The gold standard for evaluation of cerebral

aneurysms• Four vessels: – R and L verterbral arteries– R and L carotid arteries

Differential Diagnoses

Subarachnoid Hemorrhage

Management

THANK YOU!