Age: 42.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Arterial angioplasty, Blood culture, Blood sodium increased, Brain death, Brain herniation
Clinical narrative: 4/16/2021: 42-year-old female with hypertension presented to hospital with complaints of a headache.  The patient presented with the worst headache of her life beginning suddenly at 1800 on 4/15.  She described her head as feeling like it was going to explode.  She had associated photophobia and phonophobia. -CT head consistent with subarachnoid hemorrhage; CT angiography demonstrates complex anterior communicating artery aneurysm -Hypertensive; requiring IV nicardipine -New mode of pain and scalp are administered -Patient transferred to hospital -Underwent successful cerebral angiography for coiling culprit aneurysm -Mental status abnormal after procedure -Concern for bifrontal ischemic stroke noted -Episodes nonsustained sinus bradycardia; nimodipine administered 30 mg every 2 hours -Eventually underwent placement of EVD for persistently altered mental status   4/17/2021: -Mental status improved some overnight -ICP ranging between 1 and 7 since placement of EVD -Continuous EEG monitoring ongoing -Awaiting formal interpretation of this morning's TCD -Patient nods in response to questions and follows commands, but remains aphasic; she is able to write legible notes; she wants to go home but was able to express understanding of the need for very close observation for potentially more than 2 weeks   4/18/2021: -Mental status unchanged -EVD in place; ICP 0-2 -Daily TCD's, no evidence for vasospasm   4/19/21:  - ICPs 2-6 - TCD this morning shows no evidence of vasospasm.    4/20/21 - ICPs 0-6 -Awaiting formal interpretation of this morning's TCD -no major events reported overnight    4/21/2021: -Seems attentive, but answers no questions and follows no commands -Febrile, white count 7.9; blood cultures, CSF culture and urinalysis pending -TCD today demonstrates persistently elevated velocities in the left middle cerebral artery and basilar artery similar to study yesterday -ICP range between 0 and 5 so far today   4/22/2021: - TCDs normal today -pt having increased abdominal pain this afternoon -pt got extra 25 mcg of fentanyl   4/23/2021: : -Neurosurgery raised EVD to 5 -pt more agitated this morning -no vasospasm on TCD -pt had repeat head CT per neurosurgery -Underwent formal cerebral angiogram that showed significant vasospasm in the posterior circulation as well as RIGHT MCA and ACA, all treated with chemical angioplasty.  Suspected hypercoagulable state per IR due to repeat clotting off procedural catheters.  Vasc NSx added daily rectal ASA.  -Extubated following procedure, transferred back to ICU setting, but not protecting airway, required emergent reintubation by anesthesia. -Hemodynamic parameters adjusted per Vascular NSx MAP 90-110 and cardiac index 4.1 or more, phenylephrine and dobutamine added -Developed blown LEFT pupil, ICP remains <10, repeat CTH cont to show diffuse edema overall unchanged, hypertonic saline initiated following 3% bolus -EVD dropped to -5cm    4/24/2021: Repeat CTH early AM showing new, multifocal areas of infarct RIGHT frontal lobe, increased mass effect and impending vs ongoing herniation -Received 23.4% bullet after CTH findings -Increased velocities bilateral MCA on AM TCD -Developed increased ICPs in the mid to late morning 20-30s, sustained then progressed to 50s, NSx aware -Refractory intracranial hypertension, no further recommendations per Neurosciences, grave overall prognosis -Family notified of sig worsening, came to bedside and updated by Neurosurgery, Neuro IR and ICU -Further private conversations to be held with family, no further decisions regarding direction of care at this time -Family ultimately decided to update CODE STATUS to DNR, no escalation of support and reconvene on 4/25 -Patient with marked hemodynamic and ICP changes in the late afternoon/early evening, with loss of all brainstem reflexes, high suspicion for brain herniation, family aware and gift of life notified   4/25/2021: In the early a.m., patient developed high UOP, suspicious for central diabetes insipidus subsequent increase in sodium -DDAVP administered and D5 water infusion initiated -After electrolyte/acid-base derangements improved, clinical brain death testing performed with ICU and neurology services, family present at bedside -Pronounced deceased by neurologic criteria at 11:47     Discharge Condition: Pronounced deceased by neurological criteria on 4/25 at 1147.