From the Guidelines
The patient should be closely monitored for post-traumatic brain injury symptoms, particularly the persistent dizziness which may indicate ongoing neurological issues following his subarachnoid hemorrhage and frontal bone fractures. Immediate follow-up is needed to obtain and review the recent CT scan results to assess healing and rule out complications such as delayed hemorrhage, hydrocephalus, or other intracranial abnormalities, as the diagnostic yield of CT remains very low (<1%) in patients with isolated dizziness 1. In the meantime, the patient should be prescribed vestibular rehabilitation exercises to help manage dizziness, along with a gradual return to activities as tolerated. Medication options might include meclizine 25mg every 8 hours as needed for dizziness or low-dose amitriptyline 10-25mg at bedtime if symptoms persist.
The patient's clinical presentation should be evaluated using bedside tests such as the head impulse, nystagmus, test of skew (HINTS) triad to distinguish between acute brain lesions and benign pathology 1. The absence of headaches is somewhat reassuring, but given the severity of his initial injuries (subarachnoid hemorrhage and open frontal fractures), vigilance is necessary as complications can develop weeks to months after the initial trauma. The patient's age (74) and the circumstances of injury (assault in a correctional facility) are additional risk factors that warrant comprehensive follow-up care and possibly neuropsychological evaluation to assess for subtle cognitive changes that might not be immediately apparent.
Key considerations in the patient's management include:
- Regular neurological assessments including balance testing, coordination evaluation, and cognitive screening
- Monitoring for signs of autonomic dysfunction, which may contribute to persistent isolated dizziness 1
- Consideration of advanced imaging techniques, such as diffusion-weighted imaging (DWI) MRI, if associated neurologic findings are present, as the diagnostic yield of MRI increases to 12% in such cases 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient's Condition
The patient, a 74-year-old male, was treated in the ED and ICU from 2/16/2025 to 2/20/2025 for subarachnoid hemorrhage, open fracture of the frontal bone, and open frontal sinus fracture following a blunt force trauma. He complains of dizziness since the incident but denies headaches or other discomfort.
Relevant Studies
- A study published in 2012 2 found that rebleeding after subarachnoid hemorrhage is associated with multiple medical and neurologic complications, resulting in higher morbidity and mortality.
- Another study from 2009 3 defined vasospasm after subarachnoid hemorrhage and found that delayed cerebral ischemia (DCI) is a more clinically meaningful definition than symptomatic deterioration alone or the presence of arterial spasm by angiography or transcranial Doppler.
- A 2015 study 4 evaluated the effect of vasospasm and re-bleeding on the outcome of patients with subarachnoid hemorrhage from ruptured intracranial aneurysm and found that both complications can significantly influence the outcome of patients.
- A review from 2015 5 discussed rescue therapy for refractory vasospasm after subarachnoid hemorrhage, including cerebral blood flow enhancement, intra-arterial manipulations, and intra-arterial and intrathecal infusions.
- A 2018 article 6 emphasized the importance of neurological observations in patients with brain trauma, including the use of tools such as the Glasgow Coma Scale, pupillary response, and limb power observations.
Key Points
- The patient's symptoms and medical history suggest a high risk of complications related to subarachnoid hemorrhage, such as vasospasm and re-bleeding.
- Neurological observations are crucial in monitoring the patient's condition and detecting any potential complications.
- The patient's CT scan report is pending, which may provide further information on the extent of the injury and potential complications.