November 25, 2024

A 62-year-old woman was hit by a ball while playing tennis

By Med-Challenger · 2 minute read

A 62-year-old woman with no previous medical history was hit by a ball while playing tennis. Seconds after the impact she had a popping sensation in her nuchal area followed by intense headache. She was heard saying, "This is the worst headache of my life." She then became confused and began vomiting. She was taken to a local hospital where computed tomography revealed significant subarachnoid hemorrhage and early hydrocephalus. She was noted to be hypertensive with a blood pressure of 215/110 mm Hg.

The patient was transferred to the intensive care unit and a neurosurgical consult was placed. Intravenous labetalol and phosphophenytoin were started and the patient was intubated for airway protection.

What therapeutic action will be most effective in decreasing intracranial hypertension in this patient?

ventriculostomy
elevation of the head of the bed to 30 degrees
glucocorticoids
propofol infusion

The correct answer is:

ventriculostomy

Educational Objective:

Know how to reduce acute intracranial hypertension.

Key Point:

Ventriculostomy is the most effective treatment for acute intracranial hypertension.

Explanation:

The patient experienced subarachnoid hemorrhage most likely caused by the rupture of a saccular aneurysm. Immediate treatment for this neurologic emergency includes endotracheal intubation to protect the airway, neurosurgical evaluation, control of blood pressure, control of intracranial hypertension, management of comorbidities that may increase the risk of neurologic deterioration, administration of fluids and electrolytes, prevention of metabolic derangements, and discontinuation of any anticoagulants.

In cases of subarachnoid hemorrhage, hydrocephalus can develop rapidly, and the most effective treatment is ventriculostomy. Elevation of the head of the bed to 30 degrees is a simple maneuver that should be used routinely to decrease intracranial hypertension, unless the patient is hypovolemic. Analgesia and sedation, including use of propofol, also decrease intracranial pressure in the short run.

In the absence of subarachnoid hemorrhage, mannitol, an osmotic diuretic, is effective in decreasing intracranial hypertension. Glucocorticoids may be helpful in the treatment of intracranial hypertension induced by tumors or central nervous system infections, but they can be detrimental in patients with ischemic or hemorrhagic stroke.

References:

Caceres JA, Goldstein JN. Intracranial hemorrhage. Emerg Med Clin North Am. 2012;30(3):771-794.

D'Souza S. Aneurysmal subarachnoid hemorrhage. J Neurosurg Anesthesiol. 2015;27(3):222-240.

Mayor SA Hemorrhagic cerebrovascular disease. In: Goldman L, Schafer AI. Goldman-Cecil Medicine. 25th ed., 2016: 2445-2454.

This question appears in Med-Challenger Internal Medicine Exam Review with CME

Try for free and save. Ace your exams and meet your CME/MOC requirements for just $35 a month!

No matter your program, no matter the size, Med-Challenger for Groups and Institutions can better prepare your program or group, fulfill industry requirements, and increase test scores.