Medical Image of the Week: Subarachnoid Hemorrhage

Figure 1. Axial CT of the head without contrast demonstrates a large subarachnoid hemorrhage in the basal cisterns and adjacent to the insular cortices (blue arrows).

Figure 2. Coronal CT angiogram of the head demonstrates a saccular outpouching of the anterior communicating artery (blue arrow) consistent with an aneurysm.

A 70-year-old lady with a past medical history of hypertension and dyslipidemia was brought in by her family members for evaluation of confusion and headache for 1 week. There was no history of recent trauma or falls. There was no known family history of aneurysm or sudden death. On examination, her blood pressure was 139/99 mmHg, heart rate 92 bpm, afebrile and respiratory rate was 13 breaths per minute. She was alert but only oriented to self. Pupils were symmetric and reactive to light. She was able to follow commands and power was symmetric in all limbs.

CT of the head without contrast showed diffuse subarachnoid and intraventricular hemorrhage with signs of raised intracranial pressure (Figure 1). Neurosurgery was consulted and she underwent emergent insertion of an external ventricular drain. Head CT post-ventriculostomy showed improvement in her ventricular dilatation. CT angiography was performed later and showed an anterior communicating artery aneurysm (Figure 2), thought to be culprit of her subarachnoid hemorrhage. Craniotomy with surgical clipping was performed. This was followed by improvement in her mental status.

The common presenting symptom of patients with subarachnoid hemorrhage is headache. They will classically describe it as "worst headache of my life". This can be accompanied by altered mental status, nausea, vomiting, or meningeal signs. Head CT without contrast should be obtained immediately if there is suspicion of subarachnoid hemorrhage. Studies have shown that head CT is extremely sensitive if obtained within 6 hours of clinical presentation but its sensitivity declines over time (1). Lumbar puncture should be performed if head CT is negative but there is strong suspicion of subarachnoid hemorrhage. A combination of negative head CT and lumbar puncture is sufficient to rule out subarachnoid hemorrhage in a patient presented with headache (2).

Kai Rou Tey¹, MD; Tammer Elaini², MD

¹Department of Internal Medicine, University of Arizona College of Medicine- South Campus and ²Department of Pulmonary, Critical Care, Allergy and Sleep University of Arizona College of Medicine

Tucson, AZ USA

References

1. Perry JJ, Stiell IG, Sivilotti ML, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ. 2011;343:d4277. [CrossRef] [PubMed]
2. Perry JJ, Spacek A, Forbes M, et al. Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage? Ann Emerg Med. 2008 Jun;51(6):707-13. [CrossRef] [PubMed] 

Cite as: Tey KR, Elaini T. Medical image of the week: subarachnoid hemorrhage. Southwest J Pulm Crit Care. 2016;13(2):88-9. doi: http://dx.doi.org/10.13175/swjpcc063-16 PDF

Medical Image of the Week: Catheter-Induced Right Atrial Thrombus

  

Figure 1. Panel A: Apical 4 chamber view showing intra cardiac mass (arrow) in the right atrium located above the closed tricuspid valve in systole (left). Panel B: The mass moves into the right ventricle through the open tricuspid valve in diastole.

Figure 2. Axial TRUFISP MRI images through the mediastinum demonstrate a central venous catheter (yellow arrow) within the distal superior vena cava (a-b) and proximal right atrium (c).  A hypointense lesion (red arrow) is seen extending from and in close approximation of the catheter tip (d-e).  Axial T1 post-contrast MRI image through the heart demonstrates no associated enhancement (f) in this lesion. These findings are most consistent with a catheter-related thrombus. 

A 71-year-old woman with a history of renal amyloidosis complicated by end stage renal disease on long term hemodialysis through a permacath presented with complaints of recurrent syncope during hemodialysis. When propped up at 45 degrees, her examination showed an early systolic murmur located over her right upper sternal border and a crescendo systolic murmur located over left axillary region. The murmurs were grade 2/6 in intensity but increased to 4/6 when propped up at 90 degrees. A transthoracic echocardiogram revealed a 2.5 x 2.7 cm echogenic mass arising from the right atrial side of AV groove and prolapsing through the open tricuspic valve into the right ventricle during diastole (Figure 1). On contrast enhanced cardiac magnetic resonance imaging, the mass was identified as a thrombus measuring 2.9 x 2.7 x 2.2 cm and connected to the distal tip of the dialysis catheter (Figure 2).

It is difficult to confidently determine the best catheter tip position to avoid thrombosis.  Although placement of the catheter tip in the right atrium may decrease thrombosis, this location is debatable and subject to controversy (1). The optimal treatment for catheter-induced right atrial thrombus is also an area of controversy (2).  

Anticoagulation therapy is preferred over surgery by most physicians. For our patient, we treated her with warfarin to a target INR (International Normalized Ratio) of 2 to 3.  We were concerned about the possibility of thrombus detachment and catastrophic embolism. We retained the internal jugular catheter in place and obtained a new femoral access site for future hemodialysis.

Manjinder Kaur DO, Hem Desai MBBS, Emily S Nia MD, and Imo Ebong MD

Department of Medicine

University of Arizona

Tucson, AZ USA

References

1. Vesely TM. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol. 2003 May;14(5):527-34. [CrossRef] [PubMed]
2. Lalor PF, Sutter F. Surgical management of a hemodialysis catheter-induced right atrial thrombus. Curr Surg. 2006 May-Jun;63(3):186-9. [CrossRef] [PubMed] 

Cite as: Kaur M, Desai H, Nia ES, Ebong I. Medical image of the week: catheter-induced right atrial thrombus. Southwest J Pulm Crit Care. 2016;13(2):82-3. doi: http://dx.doi.org/10.13175/swjpcc062-16 PDF