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Stem
A 52-year-old hypertensive woman who smokes 20 cigarettes a day is brought to the emergency department one hour after the sudden onset of an occipital headache that reached maximum intensity within a minute. She describes it as "the worst headache of my life". On arrival she is drowsy but obeys commands (GCS 13), has marked neck stiffness and photophobia, blood pressure 178/100 mmHg, pulse 96/min, and complains of nausea. A non-contrast CT brain performed within 2 hours of onset shows hyperdense blood in the basal cisterns and the interhemispheric fissure, with a small amount of intraventricular blood but no midline shift.
Questions
a) What is the diagnosis, and which two immediate life-threatening complications must you prevent over the next two weeks? (2 marks)
The diagnosis is acute aneurysmal subarachnoid haemorrhage — the sudden thunderclap headache with blood in the basal cisterns is characteristic. The two time-critical complications to prevent are (1) rebleeding (dominant in the first 24 hours; carries about 70 percent mortality if the aneurysm re-ruptures), prevented by early aneurysm securing (coiling or clipping within 24 hours) and blood-pressure control, and (2) delayed cerebral ischaemia from vasospasm (days 4 to 14, peak 7 to 8), the leading cause of preventable death and disability, prevented by nimodipine 60 mg every 4 hours for 21 days.[1][2]
b) Outline your immediate resuscitation and the next definitive steps, naming drugs, doses, and timing. (4 marks)
Resuscitation (ABCDE):
- Airway/breathing — she is drowsy but maintaining her airway (GCS 13); give oxygen to keep SpO2 at or above 94 percent; monitor closely and intubate if the GCS drops to 8 or lower.
- Blood-pressure control before the aneurysm is secured — keep systolic BP below 160 mmHg with a titratable agent such as labetalol 10 to 20 mg IV boluses or a nicardipine infusion 5 to 15 mg/h; avoid hypotension to preserve cerebral perfusion.
- Analgesia and antiemesis — paracetamol with small opioid doses as needed, ondansetron; keep the patient calm to avoid BP spikes.
- Seizure prophylaxis is selective — give IV levetiracetam if there is a seizure or a large cortical/intraventricular clot.
- Reverse any anticoagulation; raise the head of the bed to 30 degrees; arrange an external ventricular drain if hydrocephalus develops or consciousness deteriorates.
Definitive steps:
- CT angiography to localise the aneurysm, then digital subtraction angiography if needed.
- Secure the aneurysm within 24 hours — endovascular coiling preferred over surgical clipping where the aneurysm is suitable, on the basis of the ISAT trial (lower death/dependency at 1 year with coiling: 23.7 percent versus 30.6 percent).[3]
- Nimodipine 60 mg orally (or via NG) every 4 hours for 21 days, started immediately — the only drug proven to improve outcome after SAH (Allen 1983; Cochrane 2007).[8][9]
- Transfer to a neurosciences / high-volume centre for ongoing neurocritical care.[6][7]
c) On day 7 her sodium falls to 125 mmol/L with a high urinary sodium and a falling urine output that responds to saline. Explain the likely cause and your management, and name the treatment you must avoid. (2 marks)
The likely cause is cerebral salt wasting — the commonest cause of hyponatraemia after SAH (in 30 to 40 percent of patients), driven by natriuretic-peptide release and presenting as a hypovolaemic hyponatraemia with high urine sodium and a volume-depleted state (the falling urine output that responds to saline confirms volume responsiveness). This must be distinguished from SIADH (which is volume-replete). Management is with hypertonic saline (2 to 3 percent) to correct the sodium and volume replacement to maintain euvolaemia, with fludrocortisone 0.1 to 0.2 mg orally an adjunct. The treatment to avoid is fluid restriction — appropriate for SIADH but dangerous here, because it worsens hypovolaemia, provokes vasospasm, and threatens cerebral ischaemia.[2][11]
d) On day 8 she develops a new right-sided weakness and drowsiness despite nimodipine. What is the most likely cause, and what is your management? (2 marks)
The most likely cause is delayed cerebral ischaemia from vasospasm — a new focal deficit or fall in conscious level at days 4 to 14 (peak 7 to 8) is vasospasm until proven otherwise. Confirm with an urgent CT (to exclude rebleeding or hydrocephalus) and transcranial Doppler (rising middle cerebral artery velocity). Management, after the aneurysm has been secured, is euvolaemic hypertensive therapy — maintain euvolaemia and induce hypertension (raise systolic BP to 160 to 200 mmHg with vasopressors such as noradrenaline) to restore cerebral perfusion; if refractory, intra-arterial milrinone or balloon angioplasty of the spastic vessel. Continue nimodipine for the full 21 days.[2][7]
Model answer summary
| Question | Key marking points |
|---|---|
| a) Diagnosis + two complications | Aneurysmal SAH; rebleeding (first 24 h, secure aneurysm + BP control); vasospasm/DCI (days 4 to 14, nimodipine) |
| b) Resuscitation + definitive | ABCDE; SBP below 160 before securing; CT angiography; secure within 24 h (coiling preferred, ISAT); nimodipine 60 mg q4h for 21 d; transfer to neurosciences centre |
| c) Day 7 hyponatraemia | Cerebral salt wasting (hypovolaemic); hypertonic saline + volume ± fludrocortisone; AVOID fluid restriction |
| d) Day 8 focal deficit | Delayed cerebral ischaemia/vasospasm; urgent CT; euvolaemia + induced hypertension after aneurysm secured; continue nimodipine; intra-arterial therapy if refractory |
References10ShowHide
- [1]Macdonald RL, Schweizer TA. Spontaneous subarachnoid haemorrhage. Lancet, 2017.PMID 27637674
- [2]Claassen J, Park S. Spontaneous subarachnoid haemorrhage. Lancet, 2022.PMID 35985353
- [3]Molyneux A, Kerr R, Stratton I, et al. ISAT of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms. Lancet, 2002.PMID 12414200
- [4]Perry JJ, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage. BMJ, 2011.PMID 21768192
- [5]Perry JJ, et al. Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. CMAJ, 2017.PMID 29133539
- [6]Connolly ES Jr, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage (AHA/ASA). Stroke, 2012.PMID 22556195
- [7]Hoh BL, et al. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage (AHA/ASA). Stroke, 2023.PMID 37212182
- [8]Allen GS, et al. Cerebral arterial spasm — a controlled trial of nimodipine in patients with subarachnoid hemorrhage. N Engl J Med, 1983.PMID 6338383
- [9]Dorhout Mees SM, et al. Calcium antagonists for aneurysmal subarachnoid haemorrhage (Cochrane). Cochrane Database Syst Rev, 2007.PMID 17636626
- [11]Busl KM, et al. Beyond the bleed: complications after aneurysmal subarachnoid hemorrhage. Crit Care, 2025.PMID 41029753