From rupture to recovery: neuro critical care nursing in a case of tentorial dAVF with hydrocephalus

Fathima. S^1*, Punithaselvi. D²

¹Registered Nurse, Neuro Critical Care Unit, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

²Assistant Nursing Superintendent, Neuro Critical Care Unit, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

*Correspondence

Abstract

Tentorial Dural arteriovenous fistulas (t‑dAVFs) are rare vascular anomalies with high hemorrhagic risk. When complicated by rupture and obstructive hydrocephalus, these cases demand specialized neuro‑critical care nursing. This case study presents a 35‑year‑old male with a ruptured left tentorial dAVF, associated venous aneurysm, and acute hydrocephalus. The patient underwent endovascular embolization, ventriculoperitoneal shunt placement, and tracheostomy over a 19‑day hospitalization. This article highlights the essential nursing parameters, monitoring strategies, and clinical interventions that supported successful neurological recovery to a Glasgow Coma Scale of 15/15 with independent ambulation at discharge.

Keywords: Tentorial Dural arteriovenous fistula; Subarachnoid hemorrhage; Obstructive hydrocephalus; Neuro‑critical care nursing.

Introduction

Dural arteriovenous fistulas (dAVFs) account for 10‑15 % of intracranial vascular shunts, with tentorial variants comprising only 4‑8%. These lesions lack a parenchymal nidus and directly shunt arterial blood into venous channels. When tentorial dAVFs exhibit cortical venous reflux, annual hemorrhage risk reaches 8‑13 %, with rebleeding rates of 35% within two weeks of initial rupture.

Nursing management of these patients requires vigilant neurological monitoring, intracranial pressure (ICP) optimization, prevention of secondary complications, and comprehensive rehabilitation support. This case study examines the essential nursing parameters and interventions for a patient with a complex t‑dAVF.

Clinical presentation

Parameter	Assessment
Patient	35 year old male
Presentation 2 day history of progressive gait ataxia, severe holocranial headache, projectile vomiting	2 day history of progressive gait ataxia, severe holocranial headache, projectile vomiting
GCS	on Admission 14/15 (E4V4M6), lethargic, oriented to person only
Neurological Findings	Truncal ataxia, dysmetria; no focal motor/sensory deficits; pupils equal and reactive
Vital Signs	BP 120/80 mmHg, HR 86 bpm, SpO₂ 99% RA, Temp 96.7°F
Past History	No trauma, stroke, seizures, or cardiovascular risk factors

Diagnostic findings

Imaging Studies

Study	Findings
Non contrast Head CT	Non contrast Head CT Blood in ambient cisterns, perimesencephalic spaces, occipital horns of lateral ventricles
CT Angiograph Complex high flow vascular anomaly at left ambient cistern; 7.3 × 6.1 mm aneurysmal dilation	Four Vessel DSA High flow left tentorial dAVF supplied by ILT and PCA branches; 10.1 × 5.5 mm fusosaccular venous aneurysm; retrograde drainage into basal vein of Rosenthal

Laboratory Parameters

Parameter	Value	Reference Range
Hemoglobin	14.2 g/dL	13.0 17.0 g/dL
WBC Count	9,800/µL	4,000 11,000/µL
Platelet Count	245,000/µL	150,000 450,000/µL
PT/INR	12.4 sec / 1.02 sec	11.0 13.5 / 0.80 1.20 sec
Creatinine	0.88 mg/dL	0.60 1.20 mg/dL
Serum Sodium	138 mEq/L	135 145 mEq/L
Serum Potassium	4.1 mEq/L	3.5 5.1 mEq/L

Intervention timeline

The patient’s clinical course followed a structured, multi-stage interventional timeline. On May 13, he was admitted to the emergency department where comprehensive diagnostic imaging, including non-contrast head CT, CT angiography, and four-vessel digital subtraction angiography, was performed to identify the underlying vascular pathology and guide subsequent treatment. On May 14, the first definitive intervention

Stage I: Endovascular Embolization was carried out; this involved Trans arterial embolization using a 15% Lipiodol and n-butyl cyanoacrylate (NBCA) matrix, delivered through a micro catheter under temporary balloon protection within the left internal carotid artery. This procedure successfully achieved complete occlusion of the high-flow shunt, and the 10.1 × 5.5 mm ruptured venous aneurysmal pouch. Two days later, on May 16, Stage II: Ventriculoperitoneal Shunt Placement was performed as an emergency procedure to relieve acute obstructive hydrocephalus; a Chhabra medium-pressure valve assembly was implanted, which effectively diverted cerebrospinal fluid and reduced the Evans Index from a peak of 0.42 to a normalized value of 0.30. On May 19, Stage III: Open Surgical Tracheostomy was undertaken to secure the patient’s airway, facilitate pulmonary hygiene, and support weaning from mechanical ventilation; an 8 Fr Portex fenestrated tracheostomy tube was inserted through the second and third tracheal rings. Following an uneventful recovery period with intensive neuro-critical care, the patient was discharged on June 1 with a Glasgow Coma Scale score of 15/15, intact cognitive function, the ability to ambulate with assistance, and tolerance of a regular oral diet.

Essential nursing parameters

Neurological Monitoring

Parameter	Frequency	Significance
Glasgow Coma Scale	Hourly	Early detection of deterioration, rebleeding, or vasospasm
Pupillary Response	Hourly	Indicates brainstem function and herniation risk
Motor/Sensory Assessment	Hourly	Identifies new focal deficits
Headache Assessment	Every Second hourly	Indicator of increasing ICP or rebleeding
Seizure Monitoring	Continuous	Post SAH seizure risk requires prophylaxis

Intracranial Pressure Management

To optimize intracranial compliance and prevent secondary neurological injury, a structured ICP management protocol was strictly implemented. The head of the bed was maintained at an elevation of 30 to 45 degrees, which promotes optimal cerebral venous outflow and effectively minimizes intracranial pressure. The patient’s neck was always kept in a neutral midline position to prevent jugular venous compression and avoid any unintended elevation in ICP. Nimodipine was administered at a precise dose of 60 mg every 8 hours without interruption, as this calcium-channel blocker is critical for preventing delayed cerebral vasospasm, a major cause of secondary ischemic injury following subarachnoid hemorrhage. Systemic blood pressure was carefully monitored and maintained within a target systolic range of 100 to 160 mmHg to ensure adequate cerebral perfusion pressure while avoiding hypertensive surges that could precipitate rebleeding. Additionally, the nursing team remained vigilant for early signs of elevated ICP, continuously monitoring for Cushing’s triad characterized by hypertension, bradycardia, and irregular respirations as well as pupillary changes and decreasing level of consciousness, enabling prompt detection and immediate intervention in the event of impending trans tentorial herniation.

Respiratory Parameters (Post‑Tracheostomy)

Parameter	Frequency	Intervention
Breath Sounds	Every Fourth hourly	Detects consolidation, atelectasis
SpO₂ Monitoring	Continuous	Maintain >95%
Tracheostomy Suctioning	PRN	Closed system suction; hyper oxygenate before/ after
Inner Cannula Cleaning	Every Fourth hourly	Prevents mucus plugging
Tracheostomy Cuff Pressure	20 25 cm H₂O	Prevents aspiration
Nebulization	Every Sixth hourly	Levolin/Mucyst for secretion clearance

Shunt Assessment Parameters

Parameter	Frequency	Significance
Shunt Tract Inspection	Daily	Signs of fluid tracking, erythema, tenderness
Wound Assessment	Daily	Cranial and abdominal incisions for infection.
Valve Palpation	Every 8th Hourly	Assess reservoir filling
Head Circumference	Daily	Detects changes in ventricular size
Signs of Over/ Under Drainage	Continuous	Postural headaches, vomiting, decreased LOC
Evans Index	As per imaging	Quantitative measures of ventricular enlargement

Infection Prevention Parameters

Parameter	Frequency	Intervention
Temperature	Every 4th Hourly	Detects fever; assess for infection
WBC Count	Daily	Monitor for leukocytosis
Surgical Site Assessment	Daily	Sterile dressing maintenance
Tracheostomy Site Care	Every 8th Hourly	Sterile technique, assess for cellulitis
Oral Care	Every 4th Hourly	Chlorhexidine swabbing for VAP Prevention
Hand Hygiene	Before/after contact	Standard infection control

Medication Administration Parameters

Medication	Dose	Frequency	Nursing Considerations
Levipil (Levetiracetam)	500 mg	1 0 1	Monitor for drowsiness
Nimodipine	60 mg	1 1 1	Precise 8 h schedule; monitor for Hypotension
Ivabrad	5 mg	1 0 1	Monitor HR, Maintain >60 Bpm
Pantoprazole	40 mg	1 0 0	Administer before food; stress Ulcer prophylaxis
Pulmoclear	1 Tablet	1 0 1	Monitor respiratory Improvement
KCL Syrup	15 mL	1 0 1	Monitor Potassium levels; GI tolerance
Refresh Eye Drops	2 Drops	QID	Prevent exposure Keratopathy

Rehabilitation Parameters

Parameter	Frequency	Progression
Passive Range of Motion	Every 4th Hourly	Maintain joint mobility
Positioning/Rotation	Every 2nd Hourly	Preventing pressure injuries
Mobilization Protocol	Daily	Bed → Sitting→ Standing→ Walking with assistance
SCD Application	Continuous	VTE Prevention
Swallow Assessment	Prior to Oral intake	Dysphagia screening
Nutritional Intake	Per assessment	Enteral→ Oral Soft diet progression

Outcomes

At the time of discharge on day 19 of hospitalization, the patient demonstrated an excellent clinical recovery with optimal outcomes across all parameters. Neurologically, the patient achieved a Glasgow Coma Scale score of 15/15 with fully intact cognitive function, orientation, and appropriate effect. Motor examination revealed no focal neurological deficits, and the patient was independently ambulating with minimal assistance, reflecting significant functional recovery. Respiratory status was stable with SpO₂ consistently maintained above 95% on room air; the patient was actively progressing through the tracheostomy weaning protocol with improved cough reflex and secretion management. Nutritional status had advanced satisfactorily, with the patient tolerating a soft oral diet without evidence of aspiration or swallowing difficulty. The ventriculoperitoneal shunt was functioning effectively with no clinical or radiological evidence of malfunction, infection, or over/under drainage. All vital signs remained stable and normotensive without requiring vasopressor support. Finally, the surgical sites including the cranial burr hole incision, abdominal shunt insertion site, and tracheostomy stoma demonstrated complete healing with no signs of infection, dehiscence, or cerebrospinal fluid leakage.

Discussion

This case demonstrates the critical role of neuro‑critical care nursing in managing patients with complex cerebrovascular emergencies. Key nursing considerations included:

Neurological Vigilance: Hourly GCS assessments, pupillary checks, and motor evaluations enabled early detection of rebleeding, vasospasm, or shunt dysfunction. The nursing team’s ability to recognize subtle changes in neurological status was essential to preventing secondary injury.

ICP Management: Maintaining head‑of‑bed elevation, ensuring neck neutrality and precise Nimodipine administration supported optimal cerebral perfusion pressure. The 8‑hour Nimodipine schedule required meticulous compliance to maintain therapeutic blood levels and prevent delayed cerebral ischemia.

Airway Management: The tracheostomy necessitated meticulous pulmonary hygiene including closed‑system suctioning, inner cannula cleaning, and nebulization therapy. These interventions successfully supported ventilator weaning and resolution of secondary pneumonia.

Shunt Monitoring: Daily assessment of the VP shunt tract, valve palpation, and monitoring for signs of over/under drainage enabled early identification of complications. The nursing team’s vigilance ensured early detection of potential shunt dysfunction.

Rehabilitation Support: Progressive mobilization from passive ROM to ambulation required coordination with rehabilitation services. The nursing team’s role in monitoring for signs of overexertion or neurological deterioration supported functional recovery.

Infection Prevention: With multiple invasive devices, the nursing team maintained strict aseptic techniques, assessed surgical sites daily, and coordinated antibiotic therapy for the secondary Streptococcus pneumonia infection.

The patient’s favorable outcome validates the importance of structured nursing protocols, evidence‑based interventions, and multidisciplinary collaboration in managing aggressive cerebrovascular emergencies.

Recommendations for nursing practice

Develop standardized protocols for neurological assessment, ICP management; shunt monitoring, and tracheostomy care.
Implement advanced monitoring including transcranial Doppler for early vasospasm detection where available.
Enhance nursing education on cerebrovascular emergencies through simulation training and continuing education.
Promote interdisciplinary rounds to coordinate care across multiple specialties.
Optimize transition of care through comprehensive discharge planning and patient/family education.
Incorporate rehabilitation early in the acute care setting.

Conclusion

This case demonstrates the successful nursing management of a patient with a ruptured tentorial dAVF and secondary hydrocephalus. Through comprehensive neurological assessment, ICP optimization, pulmonary hygiene, infection prevention, and rehabilitation support, the nursing team contributed to the patient’s excellent recovery. The outcome validates the essential role of neuro‑critical care nursing in supporting optimal outcomes for patients with complex cerebrovascular emergencies.

From rupture to recovery: neuro critical care nursing in a case of tentorial dAVF with hydrocephalus

From rupture to recovery: neuro critical care nursing in a case of tentorial dAVF with hydrocephalus

Fathima. S1*, Punithaselvi. D2

Nightingale Journals

Fathima. S^1*, Punithaselvi. D²