| All strokes damage the brain by disrupting circulation, | | | | comparing outcome between operated and |
| but strokes come in multiple varieties. Because | | | | unoperated patients with intracerebral hemorrhage |
| different parts of the brain are specialized to perform | | | | showed improved outcome, on average, for operated |
| specific functions, symptoms produced by strokes | | | | patients, while still others showed worsened outcome. |
| vary according to what part of the brain was injured. In | | | | Operated or unoperated, patients had high rates of |
| one patient the symptom might be weakness on one | | | | death and disability. |
| side of the body. In another it might be a partial loss of | | | | Because of the limited prospects for meaningful |
| vision. In still another, a loss of speech. And symptoms | | | | improvement, surgery for intracerebral hemorrhage is |
| can vary in intensity from mild to severe according to | | | | often an act of desperation. One crusty old clinician |
| how large the area of damage is and whether it | | | | was blunt about the direness of the situation, saying, |
| occurred in a pivotal location. | | | | "Show me a patient with intracerebral hemorrhage |
| Strokes can also vary according to another | | | | whose life was saved by surgery, and I'll show you a |
| fundamental difference -- whether they involve a | | | | patient you wish you hadn't operated on." His point |
| blocked blood vessel or a hemorrhage. Most strokes | | | | was that survivors of this operation usually show |
| are due to the former in which brain-tissue damaged | | | | severe impairments. |
| by lack of circulation is called an infarction. But 10-15% | | | | However, one form of hemorrhage within brain tissue |
| of strokes involve bleeding from ruptured blood | | | | is probably a special case, and that is hemorrhage |
| vessels within the brain tissue, and while it's bad | | | | within the cerebellum, located within the bony braincase |
| enough to have an infarction, hemorrhagic strokes | | | | just above the nape of the neck. Surgical extraction of |
| (intracerebral hemorrhages) can be even more | | | | blood clots occurring within the cerebellum prevents |
| devastating. | | | | excessive pressure on the nearby brainstem that |
| One prominent figure with spontaneous intracerebral | | | | handles a lot of basic and necessary functions, like |
| hemorrhage is Ariel Sharon, whose hemorrhagic | | | | breathing. |
| stroke occurred while he was still prime minister of | | | | Administration of cortisol-type steroids is a nonsurgical |
| Israel. Although some patients with intracerebral | | | | treatment that has been studied in a scientific way, |
| hemorrhage recover to a point of being able to enjoy | | | | comparing treated patients to untreated patients with |
| other people and regain some independence in | | | | the same condition. The steroids didn't help. Decreasing |
| functioning, Sharon's poor clinical outcome is all too | | | | the patients' blood pressures by administering |
| common in patients with this disease. | | | | medication has likewise been studied, but with the |
| The additional problem with hemorrhagic strokes is that | | | | same outcome -- no benefit. However, in a preliminary |
| the new deposit of blood occupies space -- | | | | study one nonsurgical treatment showed promise. |
| sometimes a lot of it -- and there is only so much | | | | Intravenous administration of activated factor VII (a |
| space within the skull (braincase) to go around. The | | | | natural component of the blood-clotting system) |
| fresh hemorrhage crowds and distorts the brain-tissue | | | | reduced expansion of the intracerebral blood-clot, |
| next to it, and additionally subjects the rest of the brain | | | | death and disability when given within four hours of the |
| to increased pressure that can itself be damaging. | | | | initial hemorrhage. A larger study is underway to see if |
| Because of these distortions and pressure-changes, a | | | | this benefit holds up under further analysis. |
| patient with intracerebral hemorrhage often shows a | | | | Otherwise, what can be done acutely for this |
| decreased level of consciousness or even coma. | | | | condition? Individualizing treatment seems rational, even |
| Another kind of spontaneous bleed within the | | | | if unproved. For example, if the patient had a bleed |
| braincase is subarachnoid hemorrhage, often caused | | | | while taking a blood-thinner (as was the case with Ariel |
| by ruptured aneurysms outside the brain but inside the | | | | Sharon) then it makes sense to stop the blood-thinner |
| braincase. While this, too, is a very serious condition, it is | | | | or reverse its effects. Supportive management, like |
| not the focus of this particular essay, and spontaneous | | | | administering intravenous fluids to prevent dehydration, |
| intracerebral hemorrhages are not caused by | | | | monitoring for irregular heartbeats and protecting the |
| aneurysms of this kind. Yet another kind of bleed that | | | | patient's airway also make sense. If the patient can't |
| can be confused with (primary) intracerebral | | | | consume food in the usual way, feeding through tubes |
| hemorrhage is secondary hemorrhage. This occurs in | | | | or intravenous lines can be considered, though this |
| some patients who started out with infarctions of the | | | | decision can be postponed until the patient's prospects |
| brain but who had subsequent bleeding from fragile | | | | are more apparent. |
| blood-vessels around the infarction's edges. This kind | | | | Who is at risk for intracerebral hemorrhage? |
| of bleed is not quite as serious as that which occurs | | | | Neurologists at Malmo University Hospital in Malmo, |
| when the bleed is primary (the initial event). | | | | Sweden, compared 147 patients with intracerebral |
| How are intracerebral hemorrhages diagnosed? Since | | | | hemorrhage with 1029 similar but stroke-free patients in |
| the 1970s when computed tomographic (CT) scans | | | | order to determine risk factors. They found that |
| were introduced, this imaging technique has been the | | | | hypertension (high blood pressure), diabetes, elevated |
| most effective and sensitive tool. A fresh hemorrhage | | | | triglyceride levels in the bloodstream, history of |
| within brain tissue is dramatically evident on CT scans. | | | | psychiatric problems, smoking and (surprisingly) short |
| And unlike infarctions that can take a day or two to | | | | stature were more frequent in patients with |
| show up on CT scans, hemorrhages are already | | | | intracerebral hemorrhage. |
| visible at the earliest moment a scan can be made. | | | | However, when it comes to modifiable risk-factors |
| Although surgical removal of blood-clots from the | | | | (those that one can do something about) a variety of |
| surface of the brain -- called subdural and epidural | | | | studies indicate that hypertension is the single most |
| hematomas -- can be life-saving and function-sparing, | | | | important factor. Thus, treatment of hypertension, |
| surgery for a bleed (hematoma or blood-clot) within | | | | when present, is probably the single most effective |
| the brain tissue itself is another story. Some studies | | | | thing that one can do in order to prevent this disease. |