PMC5484424_01
Computed tomography angiography (CTA) of the head. A small (~3 cc) right putaminal intracerebral hemorrhage is noted. CT spot sign is negative.
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Computed tomography (CT) of the head along with CT angiography (CTA) was obtained which showed a right basal ganglia hemorrhage measuring about 3 cc (Figure 1).
Noncontrast computed tomography (CT) of the head. (a) The right putaminal intracerebral hemorrhage has expanded to 47 cc. There is also intraventricular hemorrhage in the occipital horns of the lateral ventricles, right to left midline shift, and perihematomal edema. (b) The foramen magnum shows tonsillar herniation and effacement of the cervico-medullary junction.
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Repeat CT of the head showed hematoma expansion to 47 cc with intraventricular extension (Figures 2 and 3). There was now effacement of the basilar cisterns as well as uncal, central, and tonsillar herniations (Figures 2 and 3).
Ventilator image. After apnea test, patient was reconnected to ventilator. Prior to setting controlled ventilation with PEEP 0 and pressure support 0, it was noted that her heart rate (44 bpm) was causing small tidal volumes of 30-35 cc creating minute ventilation of 1.1 L, which we hypothesize as the cause for the slow rise of CO2 during the apnea test.
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Repeat CT of the head showed hematoma expansion to 47 cc with intraventricular extension (Figures 2 and 3). There was now effacement of the basilar cisterns as well as uncal, central, and tonsillar herniations (Figures 2 and 3). It was then noticed that she had tidal volumes of 30-35 cc with a "respiratory rate of 44" which corresponded to her heart rate on telemetry (Figure 3).
Cerebral angiography. Right carotid injection showing filling of the extracranial carotid artery but not the intracranial carotid artery which is consistent with cerebral circulatory arrest.
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Four-vessel cerebral angiography confirmed cerebral circulatory arrest (Figure 4).