Images in Clinical Medicine
Central Nervous System Hemorrhage
N Engl J Med 2009; 361:1786October 29, 2009
- Article
A 68-year-old man who had hypertension, diabetes, and atrial fibrillation and was being treated with warfarin was discovered snoring and unarousable at home. He had been in his usual state of good mental and physical health earlier in the day. There was no history of recent falls or other trauma. He was intubated by emergency medical technicians for airway protection. On physical examination, he was afebrile and his heart rate was 71 beats per minute, his blood pressure 181/100, and his oxygen saturation 100%. The score on the Glasgow Coma Scale was 3, his pupils were 8 mm in diameter and nonreactive to light, and there was no response to external stimulation. Laboratory tests revealed an international normalized ratio of 2.2. A computed tomographic image of the head, without the use of contrast material, showed a cerebellar hemorrhage extending into the midbrain and ventricles. After discussions with the patient's family, the goals of care were shifted toward comfort measures. He was extubated and died.
Joshua P. Klein, M.D., Ph.D.
Robin C. Ryther, M.D., Ph.D.
Brigham and Women's Hospital, Boston, MA
