Lesson of the Week: Reversible cardiogenic shock complicating subarachnoid haemorrhage

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Case reports Case 1—A 41 year old woman was admitted following a collapse preceded by a headache. Her initial Glasgow coma scale score was 6 and she had a fixed dilated right pupil. On intubation of the trachea, frank pulmonary oedema issued from the tracheal tube, and the chest radiograph confirmed pulmonary oedema. A cranial computed tomogram showed subarachnoid haemorrhage and a right subdural haematoma (fig 1). She immediately underwent evacuation of the subdural haematoma. After fluid resuscitation she required infusions of noradrenaline (1 μg/kg/minute), adrenaline (0.6 μg/kg/minute), and dobutamine (14 μg/kg/minute) to maintain adequate blood pressure. A pulmonary artery catheter was inserted and confirmed cardiogenic shock (table 1). The following day cerebral angiography showed an aneurysm of the pericallosal branch of the right anterior cerebral artery. An echocardiogram showed global impairment of left ventricular function. Estimated left ventricular ejection fraction was 25-30%; this deteriorated to 20% the following day. Mechanical ventilation and inotropic support were continued, and five days later the ejection fraction had improved to 40%. The aneurysm was clipped the following day, and she was discharged from intensive care seven days later. She remained in hospital for a further nine days and was then discharged to rehabilitation. At follow up, three months after discharge from our hospital, she was neurologically normal with no evidence of cardiac failure. View larger version: In this window In a new window Fig 1 Initial cranial computed tomogram in case 1, showing right subdural haematoma and subarachnoid blood View this table: In this window In a new window Table 1 Initial cardiac index, pulmonary artery occlusion pressure, worst left ventricu-lar ejection fraction, and time spent in intensive care unit Case 2—A 62 year old man was admitted to hospital after having collapsed. His family reported a seven day history of headache and vomiting. Initial Glasgow coma scale score was 14 and a computed tomogram showed an extensive subarachnoid haemorrhage with intraventricular haemorrhage and secondary hydrocephalus. Angiography showed an aneurysm of the right vertebral artery, intense spasm of the right vertebral artery, and mild spasm of the left vertebral artery. He was taken from the emergency department to the operating theatre, where a ventricular drain was inserted under general anaesthesia. Mechanical ventilation was continued because of a high requirement for oxygen and he was transferred to the intensive care unit. On admission a chest radiograph showed frank pulmonary oedema. Radial and pulmonary artery catheters were inserted and confirmed cardiogenic shock (table 1). Dobutamine (10 μg/kg/minute) and then adrenaline (0.3 μg/kg/minute) were given; noradrenaline (0.3 μg/kg/minute) was subsequently given for persistent hypotension. He remained hypoxic and hypotensive with a low cardiac index despite increasing the inotrope dose. Echocardiogaphy showed severe diffuse left ventricular dysfunction, and the ejection fraction was 30%. As he was sedated for mechanical ventilation his neurological state could not be assessed accurately. After discussion with his family an intra-aortic balloon pump was inserted. Twenty four hours later dobutamine and noradrenaline were discontinued, but the adrenaline infusion was continued for a further 24 hours. The adrenaline was then discontinued and the balloon pump removed. A repeat echocardiogram the next day showed normal left ventricular function. Eighteen days after admission the aneurysm was clipped. He remained in intensive care for a further eight days. He was discharged from hospital 41 days after admission. At follow up three months after discharge he was cognitively normal, able to look after himself without help, but had some difficulty swallowing. At the time of writing, he had no evidence of cardiac failure. Case 3—A 56 year old woman was admitted after a collapse. Her admission Glasgow coma scale was 5 and she required intubation and ventilation for pulmonary oedema. After admission to the intensive care unit echocardiography showed diffuse left ventricular dysfunction (ejection fraction 35%), and pulmonary artery catheter data confirmed cardiogenic shock (table 1). She was treated with dobutamine (7 μg/kg/minute) and noradrenaline (0.4 μg/kg/minute). Angiography showed basilar tip and right posterior communicating artery aneurysms. The day after admission she underwent craniotomy and clipping of the basilar tip aneurysm. She received intravenous nimodipine for 16 days, dobutamine for 12 days, and noradrenaline for 18 days. She was discharged from intensive care 21 days after surgery. Repeat echocardiography showed some improvement in left ventricular function (ejection fraction 40%). She was discharged from the hospital on day 31. At three month follow up she was neurologically normal with no evidence of cardiac failure. Case 4—A 50 year old woman was admitted after a collapse and respiratory arrest. She had regained consciousness after bag and mask ventilation but was confused, with pinpoint pupils, a right hemiplegia, and respiratory distress. Her admission Glasgow coma scale was 13, and she was profoundly hypoxic (arterial oxygen saturation (Sao2) 80%) owing to pulmonary oedema. Mechanical ventilation was started and she was admitted to intensive care. Pulmonary artery catheter data confirmed cardiogenic shock (table 1). Echocardiography showed severe diffuse left ventricular dysfunction (ejection fraction 30%), and she was treated with an adrenaline infusion. Computed tomography and angiography showed a subarachnoid haemorrhage from a right vertebral artery aneurysm. At craniotomy a ruptured aneurysmal dilatation of the vertebral artery consistent with dissection was found, and trapping of the right vertebral artery aneurysm was performed. She...

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