Management of a Critically Ill Patient With Severe Hypertrophic Obstructive Cardiomyopathy Presenting for Emergent Craniotomy Due to Subdural Hemorrhage

Hypertrophic obstructive cardiomyopathy (HOCM) is an inherited cardiac disorder characterized by asymmetric thickening of the myocardium, most commonly of the interventricular septum. Perioperative considerations for patients with HOCM undergoing surgical procedures are discussed, so as to avoid worsening the existing left ventricular outflow tract (LVOT) obstruction, leading to potential cardiovascular collapse. Of particular interest is managing these patients when confronted with vascular aneurysmal disease or hemorrhagic comorbidities with conflicting hemodynamic goals. In this case report, we present the case of a 77-year-old female with known HOCM and severe LVOT obstruction, presenting with intracranial hemorrhage (ICH), acute on chronic subdural hematoma, and potential cerebral aneurysm, undergoing decompressive craniectomy and hematoma evacuation. Anesthetic management of a patient with HOCM presenting for emergent ICH can be challenging given the complex hemodynamic management goals, often conflicting with a patient's comorbidities. Here we describe the prioritization of the patient's underlying HOCM pathology and favored maintenance of afterload given the potentially lethal risk of cardiovascular collapse if LVOT obstruction was encountered.