A 52-year-old Hispanic male presented from an outside hospital with head computed tomography (CT) concerning for spontaneous SAH. The patient was initially brought to an outside hospital after he was found unresponsive by his family following a bout of coughing earlier that morning. CPR was initiated for 5 min before EMS arrival, with the patient experiencing a single episode of vomiting and bladder incontinence before regaining consciousness. His family noted that the patient had complaints of chills, a mild cough, and sore throat the night before admission but was otherwise he was in his normal state of health. He had no history of prior tobacco use and otherwise had a medical history significant for hypertension without current pharmacologic treatment. There was no family history of aneurysms or any reported viral prodrome within his family contracts. His baseline modified Rankin scale (MRS) was 0.
On arrival to our institution, the patient had no complaints other than a mild headache and neck pain. Initial vitals were significant for a temperature of 39.8  C, blood pressure 157/95 mmHg, and oxygen saturation of 93% on room air. Clinical examination was notable for some mild confusion, but otherwise there were no cranial nerve deficits or focal findings on clinical exam. A noncontrast head CT demonstrated extensive SAH in the basal cisterns around the midbrain extending into the left Sylvian fissure with mild prominence of the bilateral temporal horns [Figure 1]. CT angiogram (CTA) of head and neck demonstrated a small left posterior communicating (p-comm) aneurysm [Figure 2] along with bilateral airspace disease at the lung apices, compatible with pneumonia [Figure 3]. An incidental, small right cavernous segment aneurysm and anterior communicating segment fusiform dilation were also noted. Clinical grading was consistent with a Hunt-Hess grade of 1+1 (hypertension) and modified Fisher grade of 3. Laboratory values showed no leukocytosis, platelets 125 10e9/L, sodium 135 mEq/L, BUN 14 mg/dL, and Cr 0.7 mg/dL. Liver function and coagulation studies were within normal ranges except for d-dimer, which was elevated at 1.4 mg/L (UNL 0.59) and fibrinogen, elevated at 451 mg/ dL (UNL 440). Coronavirus PCR was positive.
An external ventricular drain was placed with an opening pressure 21 mmHg. The patient was intubated before being taken to the neurointerventional suite for treatment. Diagnostic cerebral angiography of the left internal carotid artery (ICA) revealed a dominant left p-comm artery filling the posterior cerebral artery on the left with small aneurysm emanating from the junction of the left ICA and left p-comm artery, pointing posteriorly and inferiorly measuring 4 x 6 x 4 mm [Figure 4]. There was no daughter sac or evidence of extravasation of contrast. A total of six Gugliemi detachable coils (GDCs) were placed within the aneurysm leading to >95% aneurysm obliteration. A total of six Gugliemi detachable coils (GDCs) were placed within the aneurysm leading to > 95% aneurysm obliteration [Figure 5].
The patient tolerated the procedure well. He was extubated and taken to the neurological ICU (NICU) in stable condition where he was monitored for complications of SAH. A 10-day course of empiric antibiotics was completed for aspiration pneumonia. Over the course of his stay, his neurological status remained stable, however, he developed progressive hypoxemic respiratory failure and required intubation on hospital day 4 (postbleed day 3). Convalescent plasma and dexamethasone at 6 mg daily were initiated on hospital day 4, while remdesivir was held as the replication phase had passed. His initial high PEEP and FiO2 demands were weaned and he was successfully extubated on hospital day 15 and his ventricular drain removed on hospital day 13. He had no evidence of vasospasm and was downgraded from the ICU on hospital day 16. Clinically at the time of downgrade, the patient was GCS14, e4v4m6, with some intermittent confusion but otherwise appropriate without cranial nerve or any lateralizing motor deficit.
Axial CT through the lung apices demonstrating multifocal bilateral airspace disease compatible with pneumonia.