Spontaneous subarachnoid hemorrhage as a differential diagnosis of pre-hospital cardiac arrest
A 57-year-old man with no prior medical history complained of giddiness on waking up in the morning. He then fell backwards on the bed and was unresponsive. When the emergency medical services arrived at the scene 15 minutes later, the initial cardiac rhythm was pulseless electrical activity (PEA). There was no bystander CPR till then, and they immediately commenced CPR and inserted laryngeal mask airway.\nOn arrival in the ED, the patient was still in PEA. CPR was continued, and the patient was intubated. He had an episode of ventricular tachycardia, and after a single episode of defibrillation, he regained spontaneous circulation. Serial post-resuscitation ECGs showed ST elevation in aVR and ST depression in other leads []. Chest x-ray was suggestive of acute pulmonary edema. Bedside cardiac ultrasound showed normal LV contractility. Arterial blood gas analysis revealed metabolic acidosis. All the blood tests including cardiac enzymes were normal. In view of persistent hypotension, he was commenced on dopamine infusion and was mechanically ventilated.\nThe patient underwent CT scan of the brain, which showed subarachnoid hemorrhage with early ventricular extension and evolving hydrocephalus and also loss of grey-white differentiation, cerebral edema, and sulcal effacement []. After discussion with the neurosurgeon, cardiologist, and intensive care physician, the patient was admitted to neurosurgical ICU for further management. Neurosurgical intervention was not considered to be indicated by the consulting neurosurgeon, and the patient died without regaining consciousness the following day.