Illustrative Case
A 56-year-old female with no prior medical history presented
with Hunt Hess 3, Modified Fisher 4 SAH due to a ruptured
anterior communicating aneurysm. POCUS echocardiography
on admission showed unremarkable heart with good ejection
fraction. Aneurysm was protected by coiling. On post bleed day
four, she was found to have elevated TCD velocities suspicious
for vasospasm in the setting of new speech difficulties. Pressure
augmentation was initiated using vasopressors. A subclavian
central venous catheter was inserted and followed by increasing
dyspnea, acute hypoxic respiratory failure and persistent arterial
hypotension. Lung ultrasound showed normal pleural sliding
in all lung regions, so pneumothorax was ruling out. However,
multiple B lines (See Figure 1) were apparent and suggestive of
pulmonary edema. POCUS echocardiographyrevealed a dilated
left ventricle with poor contractility and apical ballooning
consistent with Takutsubo cardiomyopathy (See Figure 2) and
plethoric IVC without significant respiratory variability. Based
on these findings, a diagnosis of decompensated systolic heart
failure caused by stress cardiomyopathy. Intravenous fluids were
discontinued, and inotropic support was started with successful
blood pressure augmentation. The patient’s respiratory status
improved, and she was taken for angioplasty. All this was
completed by bedside within one to two hours’ time frame
from initial new neurological symptoms appearance. This entire
evaluation was performed by a competent neurocritical care team
in POCUS. Over the next few days, volume and blood pressure
augmentation was titrated using serial cardiac and lung POCUS
assessments. By the second week of medical management, the
patient’s TCDs normalized, systolic function improved and the
patient was discharged to floor for further clinical follow up.
Resources to Learn POCUS
Neurocritical Care Society (NCS) offers a POCUS workshop at
the annual national meeting to teach clinical applications of
ultrasound. There are many POCUS related high quality free open
access medical education resources available on the internet and
on social media (Twitter #ultrasound #POCUS #FOAMed).
We encourage the members of NCS to submit interesting cases
where POCUS has helped in management of their patients for
publication in subsequent issues of Currents. Please contact NCS if
you are interested in participating in the ultrasound workshop at
the 2018 annual meeting.
Figure 1: Lung ultrasound showing B-lines consistent with
pulmonary edema.
Figure 2: POCUS echocardiography showing parasternal long axis
view with dilated apex and poor contractility.
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