Acute left ventricular dysfunction and subarachnoid hemorrhage

Objective: Severe left ventricular (LV) dysfunction associated with acute s ubarachnoid hemorrhage (SAH) due to cerebral aneurysm rupture. Setting: An adult 12-bed surgical intensive care unit of a university hospital. Patient : A female patient presenting with SAH (Hunt & Hess grade III) and severe l eft ventricular dysfunction. Interventions: Central venous pressure, arteri al blood pressure, extravascular lung water catheter, transesophageal echoc ardiography, blood gas analysis, electrocardiograms, and chest x-ray for cl inical management. Measurements and main results: On admission to the distr ict hospital, an electrocardiogram (ECG) revealed a sinus rhythm with trans ient ST elevations. A transesophageal echocardiography showed a left ventri cular ejection fraction (LV-EF) of approximately 10%, Severe LV dysfunction required inotropic and vasopressor support to maintain mean arterial press ure above 60 mmHg, while the first measurement of an extravascular lung wat er catheter revealed a cardiac index of 2.0 L/min/m(2) and moderate hypovol emia. Despite stepwise volume loading that increased intrathoracic blood vo lume-an indicator of cardiac preload-from 719 mL/m(2) to 927 mL/m(2), cardi ac index remained poor. Enoximone lead to a marked increase of cardiac inde x up to 3.9 L/min/m(2) and LV-EF to about 30%, but had to be stopped due to thrombopenia, Surgical clipping of an intracranial aneurysm was postponed because of the impaired cardiac function and was performed on day 18 after admission. Interestingly, neurologic outcome was not as poor as might be ex pected from the literature. Conclusion: Severe left ventricular dysfunction may occur in acute SAH and may necessitate delay of aneurysm surgery.