A 58-year-old male with medical history of autoimmune deficiency syndrome, hypertension, diabetes mellitus, polysubstance abuse disorder, psychogenic movement disorder, and antiphospholipid antibody syndrome presented to emergency department (ED) with altered mental status.
Initial computed tomography (CT) head without contrast was negative for hemorrhage. The ED proceeded with performing a LP to obtain cerebrospinal fluid (CSF) for the diagnostic purpose of ruling out meningitis and HIV encephalitis. The LP yielded 20cc of bloody CSF. Of note, patient was on Coumadin for antiphospholipid syndrome and had an international normalized ratio of 2.0 and prothrombin time of 19.8. The ED failed to reverse his warfarin before performing the LP and the patient developed headache soon after, which sustained for the next few days. A second CT of the head without contrast was completed 48 h after the LP, for sustained headache and development of somnolence, which demonstrated diffuse SAH with intraventricular extension [Figure 1]. The patient was transferred to the intensive care unit for close neurological monitoring.
The patient subsequently developed low back pain, lower extremity weakness with radiculopathy, and urinary retention. Magnetic resonance imaging of the lumbar spine demonstrated ventral extra-axial hematoma measuring 1.3 cm with compression of the cauda equina most severely at L2-L3 level [Figure 2]. Neurosurgery was consulted and the patient was taken to surgery for emergent decompression of the hematoma. Intraoperatively, the dura was tense with a durotomy noted and both intradural and extradural hematomas were evacuated.
The patient's mental status remained altered postoperatively with additional deficits of the upper extremity weakness on postbleed day 13. Transcranial Doppler (TCD) demonstrated elevated intracranial velocities (right middle cerebral arteries [MCA] velocity 251 cm/s, right posterior cerebral artery velocity 104.1 cm/s, and left MCA velocity 162.1 cm/s). Lindegaard ratio was 8.7 and 4.6 on the right and left, respectively. CT angiogram revealed moderate-to-severe narrowing of bilateral MCA and anterior cerebral arteries vessels as well as moderate narrowing of the basilar artery. Patient was started on hyperdynamic therapy and underwent a cerebral angiogram for delivery of intra-arterial spasmolytic therapy, which resolved the radiographic vasospasms [Figure 3]. Throughout his hospital course, the patient underwent one additional intra-arterial spasmolytic treatment for clinical vasospasm on postbleed day 15. At that time, patient had recurrent weakness of the upper extremities as well as TCD findings suggestive for vasospasm.
The patient was discharged from the hospital 45 days after admission after completing a 3-week course in the neurocritical care unit for close observation for any subsequent vasospasm and followed by rigorous inpatient physical therapy. At discharge, the patient's upper extremity weakness had resolved, but he remained paretic in the lower extremities. He was able to feed and groom himself independently and transfer himself from bedside to wheelchair (modified Rankin score [mRS] 4). At 2-year follow-up, the patient had improvement in his lower extremity strength with some deficits noted (mRS 2).