Lesson of the Week: Reversible cardiogenic shock complicating subarachnoid haemorrhage

When rupture of a cerebral aneurysm results in cardiovascular collapse the prognosis may seem hopeless and active management may be withheld. We report five cases of aneurysmal subarachnoid haemorrhage associated with severe myocardial dysfunction and cardiogenic shock. Intensive treatment, including intravenous inotropes and intra-aortic balloon counterpulsation, resulted in good neurological and cardiovascular recovery. Patients with subarachnoid haemorrhage who develop profound cardiogenic shock should have aggressive intensive care as good recovery is likely Case 1—A 41 year old woman was admitted following a collapse preceded by a headache. Her initial Glasgow coma scale score was 6 and she had a fixed dilated right pupil. On intubation of the trachea, frank pulmonary oedema issued from the tracheal tube, and the chest radiograph confirmed pulmonary oedema. A cranial computed tomogram showed subarachnoid haemorrhage and a right subdural haematoma (fig 1). She immediately underwent evacuation of the subdural haematoma. After fluid resuscitation she required infusions of noradrenaline (1 μg/kg/minute), adrenaline (0.6 μg/kg/minute), and dobutamine (14 μg/kg/minute) to maintain adequate blood pressure. A pulmonary artery catheter was inserted and confirmed cardiogenic shock (table 1). The following day cerebral angiography showed an aneurysm of the pericallosal branch of the right anterior cerebral artery. An echocardiogram showed global impairment of left ventricular function. Estimated left ventricular ejection fraction was 25-30%; this deteriorated to 20% the following day. Mechanical ventilation and inotropic support were continued, and five days later the ejection fraction had improved to 40%. The aneurysm was clipped the following day, and she was discharged from intensive care seven days later. She remained in hospital for a further nine days and was then discharged to rehabilitation. At follow up, three months after discharge from our hospital, she was neurologically normal with no evidence of cardiac failure.