Presentation
Found unconscious on the floor, currently GCS 5, query aspiration, query intracerebral hemorrhage
Patient Data
AP semi-erect radiograph.
There is bilateral and symmetric upper lobe air space opacification, and increased density behind the heart with some air bronchograms.
The appearances in the left lower zone are most likely due to aspiration, as could the bilateral upper zone changes. However, I note the patient has had a subarachnoid hemorrhage, and the bilateral upper lobe appearances could represent with non-cardiogenic pulmonary edema. The final differential would be infection.
Large volume of widespread subarachnoid hemorrhage predominately focused on the septum pellucidum with intraventricular extension and significant hydrocephalus.
No shift of the midline structures. No skull fracture.
Impression:
Subarachnoid hemorrhage with interventricular extension.
Case Discussion
Subsequent CT angiography demonstrated a 4mm aneurysm arising from the anterior communicating artery.
The chest radiograph demonstrates a distribution in keeping with non-cardiogenic pulmonary edema with a bilateral and symmetrical upper lobe distribution, with a relative sparing of the peripheral lung parenchyma. However, the differential for these appearances are quite broad and include aspiration and infection.
Given this patient's clinical presentation with subarachnoid hemorrhage we considered non-cardiogenic pulmonary edema to be the likely cause of these findings. However, as the left lower lobe consolidation certainly fits with aspiration it is possible that the multifocal changes are all due to aspiration, however given the distribution this is deemed less likely.