explained to the callers that obtaining a head CT was
prudent. Despite the buddies’ conviction that the diver had
sustained an AGE, it was in their friend’s best interest to
make sure the condition had no other cause. However, the
medics’ reassurances did not help abate the buddies’ fears.
They both insisted DAN medics speak to the attending
physician to explain that treatment in a chamber was most
important. The DAN medics again agreed that AGE was
possible, but they reiterated that other causes had to be
ruled out.
Diagnosis, Treatment and Recovery
The head CT showed bleeding in the cerebrum — a
hemorrhagic stroke — due to a perforated cerebral artery,
and the diver was immediately taken into surgery. During
surgery, he was found to have a bleeding aneurysm, which is an
abnormal weak area in an artery. Aneurysms may be congenital
or the result of long-standing, untreated hypertension.
After successful repair, the diver was admitted to the
neurological intensive care unit. The initial bleeding
caused swelling of the brain, which resolved over the
next two weeks. During that period the diver regained
consciousness, remained in stable condition and began to
recover strength in his right side. He was transferred from
the intensive care unit to a rehabilitation facility, where he
spent three months undergoing physical and occupational
therapy. He recovered enough function in those three
months to allow him to return home. Within six weeks
of being at home and continuing to undergo therapy, all
deficits resolved completely.
Discussion
Stroke is the third leading cause of death and the leading
cause of long-term disability in the United States. While
AGE was certainly a consideration in
this case, determining the presence or
absence of stroke had to take priority.
While few clinicians are dive-medicine
experts, decompression illness (DCI)
is rare and is most often a diagnosis of
exclusion, which means it is generally
arrived at once other possible diagnoses
are ruled out. The need to review
alternate explanations of this diver’s
symptoms was particularly important
given the lack of any history of rapid
ascent or breath holding. It is very
unlikely diving contributed to the
rupture of the aneurysm.
It is important to recognize that not
all signs and symptoms following dives
automatically indicate dive accidents. As
this case illustrates, signs and symptoms
that suggest DCI may actually represent
an entirely different problem. Despite
the strong suspicion of AGE in this
case, the treating doctor appropriately
screened for stroke, the most severe and
likely cause that would explain unilateral
weakness, pupil dilation and sudden loss of consciousness.
DAN frequently consults with emergency departments
and provides dive-medicine information, which can assist
clinicians in making accurate diagnoses. DAN is here to
help symptomatic divers, their buddies and the health-care
professionals who treat them. While prompt treatment of
DCI in a hyperbaric chamber is the general goal, ruling out
other serious explanations must often take precedence. In
this case, delaying surgery by five or more hours could have
resulted in persistent neurological deficits. In the end, the
goal of medical practice is to apply a thoughtful diagnostic
approach to the symptoms present and to determine and
effect the most appropriate treatment.
AD
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