Carbon dioxide
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First report of subarachnoid haemorrhage in a patient undergoing diagnostic challenge: case report A woman with moyamoya syndrome experienced a subarachnoid haemorrhage during diagnostic testing with carbon dioxide. In 2005, at 32 years of age, the woman had been diagnosed with severe vasculopathy consistent with moyamoya syndrome, considered related to her chronic methamphetamine use. About 2.5 years later she presented with postural transient ischaemic attacks which became more frequent and severe. She was considered for surgical revascularisation, and underwent evaluations including transcranial Doppler ultrasound imaging with assessment of vasomotor reactivity to carbon dioxide. Through a mouthpiece she received carbon dioxide (approximately 6%)-enriched medical grade oxygen and measures were taken while she was hypercapneic (end tidal CO2 50 mm Hg); she was then instructed to hyperventilate to an end tidal CO2 of 24 mm Hg. At the completion of hyperventilation she developed "the worst headache of her life", and was writhing in pain. Emergent CT revealed a parafalcine subarachnoid haemorrhage. The woman was admitted for observation [outcomes not stated]. Author comment: "[W]e propose that the [subarachnoid haemorrhage] was precipitated by the acute changes in PaCO2 which led to an additional hemodynamic stress, vasodilation followed rapidly by vasoconstriction, on the dilated, thinned, fragile pial collaterals resulting in vessel rupture, likely related to abnormal vascular architecture, and [subarachnoid haemorrhage]." Donohue MM, et al. Transcranial Doppler ultrasound CO2 challenge complicated by subarachnoid hemorrhage in patient with moyamoya syndrome. Neurocritical 803050925 Care 13: 243-6, No. 2, Oct 2010 - USA
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Editorial comment: A search of AdisBase, Medline, Embase and the WHO ADR database did not reveal any previous case reports of subarachnoid haemorrhage associated with carbon dioxide.
0114-9954/10/1342-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved
Reactions 12 Mar 2011 No. 1342
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