Setting 57-year-old female patient with a past medical history of ischemic cardiomyopathy, non-stentable coronary stenosis and a myocardial infarction at age 41. Chronic treatment: Asaflow, bisoprolol, a lipid-lowering agent, and isosorbide as needed.
The patient suffered a witnessed cardiac arrest in the presence of a physician friend who immediately initiated resuscitation (no no-flow time). Advanced emergency services arrived within 6 minutes. ROSC was achieved after three electrical cardioversions. No adrenaline was administered. She was admitted to the nearest regional hospital.
ICU
On admission: Blood pressure: 200/120 mmHg, Heart rate: 90 bpm, Respiratory rate: 15 (volume-controlled ventilation), Core temperature: 35.4°C, SpO₂: 100%, Pupils isochoric and isoreactive, GCS: E1VTM4 under continuous midazolam infusion (5 mg/h), No signs of shock.
Examinations
ECG was normal, with no arrhythmias or ST changes to explain the cardiac arrest. Bedside echocardiography was reassuring.
Lab results showed a D-dimer of 12,261 and a troponin of 28.9.
CT pulmonary angiography ruled out pulmonary embolism.
Coronary angiography revealed no significant coronary lesions.
Neurological fluctuations were noted during neurological assessment windows. A CT scan performed 48 hours later showed hemorrhage in the basal cisterns, along with a fine subarachnoid hemorrhage in the peri-encephalic region, without a clear epicenter. The bleeding was particularly abundant in the peribulbar and pontine regions, extending to the perimedullary space, and was associated with hydrocephalus. No vascular source was identified on the CT angiography sequences.
Clinical evolution
An external ventricular drain was urgently placed. MRI revealed a perimedullary hematoma from C1 to D3, which was surgically drained via decompressive laminectomy. The patient was transferred on Day 3 to a specialized neuro-ICU under sedation, with a diagnosis of subarachnoid hemorrhage with modified Fisher grade III, WFNS grade 4, sine materia.
She continued with EVD drainage for hydrocephalus.
Tetraplegia was observed, with sensory loss up to T4. Extubation attempt failed due to absent airway protective reflexes. Consciousness was preserved throughout.
GCS E4VtM6, with communication via eye movements.
The patient was able to express her refusal to accept a state of severe disability.
Therapy included standard care with norepinephrine (0.1 mcg/kg/min), sedation until Day 4, levetiracetam until Day 5, nimodipine.
Sudden change of the clinical status
On Day 11: The patient experienced a sudden loss of consciousness. GCS dropped to E1VTM1.
