Rita Jones, age 52, was admitted 7 days ago with a ruptured anterior communicating artery aneurysm, which caused a subarachnoid hemorrhage. After undergoing aneurysm coiling to stop the hemorrhage, she was admitted to the neuroscience intensive care unit to recover. Yesterday, she was transferred to the neuroscience step-down unit. The nurse’s report states she has been alert and oriented to person, time, and place; tolerates being out of bed in a chair most of the day; and is tolerating a regular diet.
History and assessment hints
When you enter the patient’s room with her morning medications, you find her slumped in a chair. She opens her eyes when you call her name but doesn’t verbalize answers to your questions. When you ask her to squeeze your hand, she grabs it strongly with her right hand but doesn’t move her left arm.
You get help to lift her back to bed, and then obtain vital signs. Her blood pressure is 105/68 mm Hg; heart rate, 115 beats/minute; respiratory rate, 18 breaths/minute; and oxygen saturation on room air, 93%. Her pupils are equal at 3 cm bilaterally and reactive to light.
Call for help
You realize Ms. Jones is deteriorating neurologically, with probable aphasia and new-onset left-sided paralysis. In fact, you suspect she’s having a stroke—possibly from a vasospasm brought on by the subarachnoid hemorrhage. You immediately call the rapid response team (RRT).
On the scene
When the RRT nurse arrives, she begins to administer oxygen 2 L via nasal cannula and performs a neurologic assessment. She finds Ms. Jones is aphasic and unable to move her left arm or leg. She notes that her blood pressure is low, and asks you to start a peripheral I.V. line and hang a 1,000-L bag of 0.9% sodium chloride at a wide-open rate.
Then she calls the neurosurgeon, who orders a STAT transcranial Doppler (TD) exam to measure cerebral blood flow in key cerebral arteries. The result indicates Ms. Jones is having a cerebral artery vasospasm. She’s transferred to the interventional radiology department for cerebral angiography with intra-arterial vasodilator therapy.
Over the next 6 days, Ms. Jones receives medications to maintain her systolic pressure above 150 mm Hg and thus perfuse blood through her constricted cerebral arteries. Daily TD studies show her cerebral artery vasospasms are subsiding slowly, restoring normal cerebral blood flow. Her left-sided paralysis improves to left arm and leg weakness, and her speech returns to normal. She is transferred back to the step-down unit, and 3 days later is discharged with orders for outpatient physical therapy to continue her physical improvements.
Education and follow-up
Aneurysm rupture results in a type of hemorrhagic stroke called a subarachnoid hemorrhage. As blood released by the hemorrhage begins to break down, it irritates the surrounding cerebral arterial vessels, triggering vasospasms and reducing blood flow to the affected part of the brain. This common complication usually occurs 5 to 10 days after aneurysm rupture and leads to signs and symptoms of an ischemic stroke. Vasospasm is treated by instilling vasodilator medications directly into the vasospasm area via cerebral arteriography, along with maintaining euvolemia and elevating blood pressure to force blood through narrowed arteries and restore cerebral blood flow.
Teach patients and families to continue at home with any ordered therapies to help the patient continue to gain strength and independence. Nimodipine, a calcium channel blocker, has been shown to decrease vasospasm incidence; typically, it’s prescribed as 60 mg P.O. every 4 hours and must be continued for 21 days. Emphasize the importance of taking this medication for the full 21 days, preferably on an empty stomach
- Diringer MN, Bleck TP, Claude Hemphill J 3rd, et al.; Neurocritical Care Society. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15(2):211-40.