Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Persistent Altered Mental Status


Consult Page

60M with AMS and sepsis with SAH found on MRI to have possible vascular lesion. Consulting for further recs.

Initial Imaging

Fig. 29.1, A. An axial T2 FLAIR sequence brain MRI shows subarachnoid blood within the sulci of the right frontoparietal region (arrow). A flow void can be seen in the right parietal region (asterisk). B. An axial T2 sequence demonstrates flow voids within the right parietal region, likely representing engorged veins from a dAVF.

Walking Thoughts

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    What has been the patient’s hospital course so far? What other comorbidities does the patient have?

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    What other etiologies could be contributing to the patient’s altered mental status? What work-up has been performed for this?

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    What is the GCS of the patient? Is he able to protect his airway?

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    Where is the location of the subarachnoid hemorrhage (SAH)? How severe is the SAH (diffuse or focal, thickness)?

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    Is there any intraventricular hemorrhage or hydrocephalus? Does the patient need an external ventricular drain?

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    Does the patient require additional imaging?

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    Is the patient taking anticoagulant or antiplatelet medications?

History of Present Illness

A 60 year old male with a history of chronic kidney disease requiring dialysis, hypertension, hyperlipidemia, prior right hemicolectomy, and nephrolithiasis is admitted to the medical intensive care unit (MICU) for lethargy and respiratory distress.

The patient had been experiencing fever and chills for two weeks prior to admission. Family reported that he became progressively more somnolent and was found unresponsive at home. He was brought to the emergency department where he was found to be septic in the setting of multifocal pneumonia. He was intubated and admitted to the MICU. Due to his altered mental status, a head CT was performed which was negative for intracranial hemorrhage. Despite broad spectrum antibiotic treatment, the patient had persistently poor mental status. He underwent a brain MRI without contrast (no contrast was administered due to his poor renal function), which showed thin SAH in the right frontoparietal region with a right parietal vascular lesion ( Figure 29.1 ). Currently, he remains intubated on minimal sedation.

He does not take any antiplatelet or anticoagulant medications.

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