A 49-year-old right-handed male presented to a local community hospital with headache and progressive right-sided weakness. His past medical history included renal cell carcinoma, in remission for the past 3 years, treated by surgical resection and chemotherapy. The computerized tomography (CT) scan of the head performed on the day of presentation revealed a large hemorrhagic lesion in the left central region of the brain highly suspicious of a tumoral bleed, as well as significant peri-lesional edema, severe midline shift and uncal herniation (Figure 1).
Within 2 hours of his arrival, the patient deteriorated, with a drop in Glasgow Coma Scale (GCS) from 15 to 12 prompting urgent intubation prior to transfer to our hospital. Upon arrival in our emergency room, the patient’s neurological examination revealed non-reactive pupils, absent corneal reflexes and extremely abnormal eye movements on oculo-cephalic reflex testing. The patient was hyperventilated and given a 200 mL bolus of 20% mannitol (0.58 g/kg). A repeat CT scan to rule out further hemorrhage showed no change from the previous in terms of hemorrhage, swelling or brain stem compression. A neurologic exam performed immediately after the CT scan, 30 minutes after the mannitol bolus, the patient had deteriorated with absent pupillary response, absent corneal reflexes and a total lack of eye movement on oculocephalic reflex testing, no spontaneous breathing and extensor posturing in the extremities to painful stimuli. It was felt that the patient was not salvageable. Before calling in the family and withdrawing active care, a transcranial Doppler (TCD) was performed in the emergency department to assess cerebral flow. The TCD was performed by the first author (a neurosurgeon and a neuro-intensivest), using a P4-1c Phased Array probe (ZONARE Medical Systems, Inc., Mountain View, CA, USA), operated at 2–3 mHz to insonate the temporal windows bilaterally. There was reverberating flow in the left middle cerebral artery (MCA) compatible with cerebral circulatory arrest on that side, but a high resistance pattern of flow in the right MCA (Bellner et al. 2004). Optic nerve ultrasonography was also performed and showed bilateral dilatation of the optic nerve sheath compatible with intracranial hypertension (Soldatos et al. 2009) (Figure 2).
Because of the presence of flow demonstrated in the right MCA, the patient was given another 500 mL of 20% mannitol (1.53 g/kg) over five minutes with close monitoring of his blood pressure. Within a few minutes the TCD examination showed the return of circulation in both hemispheres along with a reduction in the diameter of the optic nerve sheaths bilaterally (Figure 3). Immediately after the TCD the patient was examined and had reactive pupils. Several minutes later he was localizing to pain with his left side. Based on this favorable response, the patient was rushed to the operating room for a decompressive craniectomy and expansive duraplasty along with evacuation of the hematoma and tissue sampling of the hemorrhagic mass. The patient was observed in the intensive care unit for a few days and then transferred to the neurosurgical ward awaiting further treatment for his lesion (biopsy revealed a glioblastoma). Upon transfer to a rehabilitation center, he still had significant right-sided weakness and dysphasia. He had no residual brain stem dysfunction and repeat imaging showed resolving hemorrhage and residual tumor as expected, as well as a left posterior cerebral artery ischemic stroke likely from the herniation syndrome the patient sustained at the beginning of his hospital course.