Aashi
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A 38-year-old woman is admitted with an excruciating headache, photophobia, nausea, and vomiting for the last hour. Her temperature is 98 F, and her blood pressure is 172/90 mm Hg. She has a stiff and painful neck with no focal neurological deficits and no cranial nerve palsies. A CT scan of her head reveals the presence of a subarachnoid hemorrhage with no intraparenchymal blood. A four-vessel angiogram does not reveal the source of bleeding, and there are no aneurysms or arteriovenous malformations. She is started on nimodipine and is stable for six days.
On the sixth day, she develops mild weakness of the right arm and leg. She is awake, alert, and oriented, and is in no respiratory distress. She is now afebrile with a blood pressure of 128/62 mm Hg. A repeat CT scan of the head shows no evidence of fresh blood. The transcranial Doppler shows increased velocity of blood flow and narrowing in the middle cerebral artery. What is the next step in management?
(A) Repeat angiogram
(B) Increase the mean arterial pressure with crystalloids and dopamine
(C) Start antihypertensive medications
(D) Intubation and hyperventilation
(E) Ventriculostomy
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| ling
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b?
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| prathapdoctor
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increase the mean arterial pressure with crystalloids and dopamine.
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| drashishmahajan
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D
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| CocaCola
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B - Increase BP
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| robin082006
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give your explanation1
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| Aashi
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Answer:
(B) Increase the mean arterial pressure with crystalloids and dopamine
Explanation:
Cerebral perfusion pressure is defined as the mean arterial pressure minus the intracranial pressure. The patient is this case presented with cerebral vasospasm six days after the initial subarachnoid hemorrhage. This was confirmed by the transcranial Doppler. The repeat CT scan of the head showed no evidence of fresh blood. At this point, the cerebral perfusion pressure should be increased by raising the mean arterial pressure with crystalloids and dopamine. Repeating the angiogram is not indicated because the transcranial Doppler already showed spasm of the middle cerebral artery. Antihypertensive medications are not indicated unless the blood pressure is much higher. Intubation and hyperventilation and the ventriculostomy are indicated when there is an abnormally increased intracranial pressure, leading to a decrease in cerebral perfusion. Nimodipine has only a limited role in preventing vasospasm of the cerebral vessels. If spasm occurs while on nimodipine, there are few therapeutic alternatives, one of which is to volume expand the patient and try to increase the cerebral perfusion pressure. This will hopefully overcome the vasospasm and increase flow through the narrowed vessel.
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