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Chronic hydrocephalus as a sequela of subarachnoid hemorrhage is a complication that neurosurgeons battle with every day. This chapter presents a case study of a 49-year-old female presented to the hospital with fever and altered mental status. Computed tomography (CT) scan of the head revealed acute hydrocephalus, with ventriculomegaly and hypodensity in the surrounding whitematter representing transependymal translocation of cerebrospinal fluid (CSF). The diagnosis of acute hydrocephalus is made based on CT scan evidence of subarachnoid hemorrhage (SAH) or intraventricular blood, with or without the presence of enlarged ventricles, as well as a declining mental status. As the popularity of endovascular treatment of ruptured cerebral aneurysms has grown, there has been speculation that this treatment modality results in a higher incidence of shunt-dependent hydrocephalus. Although necessary for the treatment of chronic hydrocephalus, ventriculoperitoneal shunt (VPS) are fraught with complications.
Hypotension is one of the most common findings in the intensive care unit (ICU) patient and requires prompt attention in order to avoid poor clinical outcomes. This chapter presents a case study of a 42-year-old morbidly obese female who was transferred to the ICU after being diagnosed with a subarachnoid hemorrhage due to a ruptured aneurysm of the right middle cerebral artery. The patient's hypotensive condition was corrected by fluid boluses to increase her filling pressure, guided by pulmonary capillary occlusion pressure (PCOP) and by starting the patient on norepinephrine infusion to increase her cardiac output and maintain her perfusion pressure as well. Cardiac output itself is determined by several interrelated factors: mainly preload, pump function, and afterload. Basic principles of physiology help with the differential diagnosis of hypotension. Prompt management of hypotension often requires invasive monitoring, fluid resuscitation, and the use of vasopressor or inotropic therapy.