Should a patient with a history of subarachnoid hemorrhage (SAH) secondary to cocaine abuse, status post (s/p) burr hole surgery and external ventricular drain (EVD) placement, be monitored with imaging?

From the Guidelines

Yes, you should monitor imaging for this patient with a history of subarachnoid hemorrhage (SAH) secondary to cocaine abuse who underwent burr holes and external ventricular drain (EVD) placement in March 2024. I recommend scheduling a follow-up brain MRI or CT angiogram within the next 1-3 months, and ensuring the patient sees a neurologist within 4-6 weeks. This patient requires neuroimaging to assess for potential complications such as cerebral vasospasm, hydrocephalus, or aneurysm formation, which can develop after SAH, as suggested by the American Heart Association/American Stroke Association guideline for the management of patients with aneurysmal subarachnoid hemorrhage 1. The fact that she has residual tension headaches is concerning, even though they're partially managed with ibuprofen and gabapentin. While her lack of visual changes is reassuring, the absence of neurological follow-up is problematic. Additionally, the patient should be counseled about cocaine abstinence, as continued use significantly increases the risk of recurrent hemorrhage, and consider referring her to addiction services if not already done, as recommended by the ACR Appropriateness Criteria for cerebrovascular diseases-aneurysm, vascular malformation, and subarachnoid hemorrhage 1. Blood pressure management is also crucial, so regular monitoring and appropriate treatment should be implemented. The patient should be educated about warning signs requiring immediate medical attention, including sudden severe headache, confusion, seizures, or focal neurological deficits. Some key points to consider in the management of this patient include:

• The importance of follow-up imaging to monitor for potential complications after SAH, as outlined in the ACR Appropriateness Criteria 1
• The need for neurological follow-up to assess for any changes in the patient's condition, as recommended by the American Heart Association/American Stroke Association guideline 1
• The importance of counseling the patient about cocaine abstinence and referring her to addiction services if necessary, as suggested by the ACR Appropriateness Criteria 1
• The need for regular blood pressure monitoring and appropriate treatment to reduce the risk of recurrent hemorrhage, as recommended by the American Heart Association/American Stroke Association guideline 1

From the Research

Monitoring for HX SAH Secondary to Cocaine Abuse

The patient in question has a history of subarachnoid hemorrhage (SAH) secondary to cocaine abuse, with recent burr holes and external ventricular drain (EVD) placement. Given this medical history, it is essential to consider the potential complications and necessary monitoring.

Potential Complications

• Hydrocephalus: Although studies such as 2 found no significant difference in the risk of hydrocephalus in SAH patients with a history of cocaine use, it is still a potential complication that requires monitoring.
• Cerebral vasospasm: Cocaine use has been associated with an increased risk of vasospasm in SAH patients, as reported in 2.
• Re-bleeding: While 2 found no significant difference in the risk of re-bleeding, it is still a potential complication that needs to be considered.
• Neurological and systemic complications: SAH patients are at risk for various neurological and systemic complications, including delayed cerebral ischemia, seizures, and neuroendocrine abnormalities, as discussed in 3.

Imaging Monitoring

• Noncontrast brain computed tomography (CT): This is a recommended initial imaging modality for diagnosing SAH, especially within 6 hours of symptom onset, as stated in 4.
• Lumbar puncture: If the initial CT is normal but clinical suspicion remains high, a lumbar puncture may be considered for definitive diagnosis, as suggested in 4 and 5.
• Cerebral MRI: This may be proposed if the patient's clinical condition allows it, as it offers greater sensitivity for diagnosing restricted subarachnoid hemorrhage in cortical sulcus, as mentioned in 5.
• CT angiography: This is recommended in the early phase to identify the cause of SAH and investigate for an intracranial aneurysm, as stated in 5.

Follow-up Care

Given the patient's history of SAH and cocaine abuse, regular follow-up with a neurologist is crucial to monitor for potential complications and adjust treatment as necessary. The patient's current medication regimen, including ibuprofen and Gabapentin, should be evaluated for effectiveness in managing residual tension headache, as reported in the patient's history.