Status post subarachnoid haemorrhage with gait disorders and lower limb contractures – a case study
Prepared by the NORMAN Neurological Rehabilitation Centre.
This case study does not constitute medical advice and does not replace a consultation with a specialist or an individual diagnosis. For questions about your own health, please contact a doctor or physiotherapist.
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Patient details
Sex
Male
Age
49 years old
Main diagnosis
- status post subarachnoid haemorrhage from a ruptured aneurysm of the left internal carotid artery
- post-haemorrhagic hydrocephalus
- status post external ventricular drainage
- status post ventriculoperitoneal shunt implantation
- left-sided hemiparesis
- gait disorders requiring the use of a walking frame
Comorbidities
- other extrapyramidal and movement disorders
- a history of epilepsy
- unstable coronary artery disease
- angina pectoris
- organic mood disorder
- cachexia
- deep pressure ulcers of the sacral region and the left hip, subsequently healing
- flexion-adduction contractures of the hips
- flexion contractures of the knees
- suspected periarticular ossification of the hips
- painful left shoulder syndrome following injury to the shoulder and arm
- a past urinary tract infection
- past meningitis
- a history of drug rash
Functional status
This case describes a patient following a subarachnoid haemorrhage from a ruptured aneurysm of the left internal carotid artery, complicated by post-haemorrhagic hydrocephalus. Initially the patient was bedridden, cachectic, with impaired contact and with deep pressure ulcers of the sacral region and the left hip. It was noted that he had not previously been verticalised because of the contractures.
On functional assessment, the most striking findings were extensive flexion-adduction contractures of the hips and flexion contractures of the knees. Limitation of extension at the hips and knees was described, which decreased in the course of rehabilitation. Initially the patient was unable to turn onto his side unaided, helped himself with his hands when sitting up and required support. After a few minutes of sitting he reported dizziness. In the early period he also reported very severe pain in the buttocks and shoulder.
Improvement was noted in changing position, sitting up, verticalisation and walking, as a result of work on gait and balance disorders. The patient was able to stand up unaided from a lying position, get out of bed independently, walk to the toilet and move around with the aid of a walking frame. He maintained full balance while seated. He was able to stand alone without support or supervision. He no longer reported dizziness, and the pain in the buttock region and the shoulder joint had resolved.
In terms of communication, verbal contact was described as entirely coherent. The patient ate independently. Voice strength and phonation duration were normal and coordinated with breathing. The motor function of the articulatory organs was normal. In spontaneous speech he occasionally confused words of similar meaning or sound, and perseverations occurred in his utterances, which justified further support as part of speech rehabilitation. Word-finding difficulties occurred sporadically. Writing attempts showed less legible handwriting, with occasional difficulty in reading his own notes.
Significant medical events
The clinical course involved a subarachnoid haemorrhage from a ruptured aneurysm of the left internal carotid artery, after which clinical and radiological features of acute post-haemorrhagic hydrocephalus developed. Embolisation of the aneurysm, implantation of an external ventricular drain and subsequent implantation of a ventriculoperitoneal shunt were noted. Follow-up imaging described a reduction in the size of the ventricular system, correct positioning of the shunt and no features of fresh bleeding.
In this case, meningitis, a drug rash, suspected aspiration pneumonia and a urinary tract infection occurred. Appetite disturbances, cachexia and an organic mood disorder were also described. Following a psychiatric consultation, an improvement in mood and appetite and weight gain were noted.
During transport for follow-up imaging, chest pain occurred. The patient was hospitalised for unstable angina pectoris. Coronary angiography revealed a stenosis of the left anterior descending branch of approximately 50–60%, and in further management the patient was qualified for conservative treatment of the coronary artery disease.
A neurological consultation described painful left shoulder syndrome following injury to the shoulder and arm, considerable limitation of shoulder mobility and painful thickening in the proximal part of the arm. Contractures of the hips and knees and suspected periarticular ossification of the hips were also noted.
Patient status on completion of hospital treatment
On completion of hospital treatment, the patient was in good general condition. Verbal contact was entirely coherent. The patient sat up and stood up unaided and walked with the support of a walking frame. The pressure ulcers were in the process of re-epithelialisation.
An improvement in the range of movement of the lower limbs, in the quality of sitting and balance, and the ability to walk a dozen or so metres with a frame were noted. The patient actively assisted during transfer to a wheelchair, changed position in bed without being prompted, and was able to sit in the wheelchair for about 30 minutes.
Continued care by a general practitioner and specialist reviews, including neurosurgical and cardiological, were recommended. A review at a mental health clinic, a low-lipid diet, adequate hydration, daily monitoring of blood pressure and pulse, and regular medication were also indicated. Further work on the patient's motivation, encouragement to take part in domestic and household activities, strengthening of the lower limbs and pelvic stabilisers, and an interdisciplinary approach to reducing the flexion contractures of the hips and knees were recommended.
Next stage of rehabilitation
On completion of hospital treatment, the patient continued the rehabilitation process as part of neurological rehabilitation programmes. The importance of starting rehabilitation appropriately for the results achieved should be emphasised. Further speech and language therapy was recommended, along with further management focused on activation, walking, everyday activities and reducing the contractures.
Rehabilitation programmes matched to this case
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Neurological rehabilitation staySymptoms and deficits described in this case
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