Podcast Transcript — Episode 43: Catastrophic Brain Bleeds (Part 3)

Drs. Ayesha and Dean Sherzai take a deep dive into the topic of brain bleeds and hemorrhagic strokes. Read the full transcript of this episode below.

Ayesha Sherzai (00:05)

Welcome to the Brain Health Revolution Podcast with your hosts Ayesha and Dean Sherzai.

Friends, I’m very excited to bring this next episode to you all. The subject is brain bleeds or cerebral hemorrhage. We’ll take a deep dive into the epidemiology of this condition, the diagnosis, the different symptoms, treatments and prevention. It’s a pretty devastating disease. And we hope you take a listen to it and enjoy the information that we’re bringing to you, but before we start the episode I’d like to tell you guys about Neuro Academy.

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Thank you so much for joining us today.

Mary is a 62 year old middle school teacher who is fairly active runs about three miles every single morning, takes care of her family and is generally thriving. She started experiencing some episodes of dizziness and on one particular morning she was feeling fine. But after her run, she took a warm shower and coming out of the shower she felt lightheaded and stumbled and fell and on the way down she hid the back of her head against the sink.

The impact was pretty significant but not enough to knock her out. She got right up felt slightly dizzy and felt a little pain in the back of her head for a few seconds. But it didn’t really stop her from dressing and getting ready for the day. She walked downstairs and started talking to her husband mentioned that she fell and how they needed to buy better bathroom floor mats so nobody slips anymore. And she started speaking about general stuff with her family and got busy with her chores.

Her head felt a bit sore, but she felt okay and decided not to go to the emergency room. About an hour later, when she was about to get ready to go out. She suddenly started having some shooting pain in the back of her head. It was radiating. And she just attributed to the superficial pain from the head trauma and didn’t think of it as anything else anything serious.

Over the next few hours, the headache got worse and worse to the point that she couldn’t stand anymore and she felt very lightheaded, and any sound or light made it excruciating. She was also becoming very lethargic at this point. Mary’s husband, Tom decided that this was not normal. And he quickly reached out for his phone and called 911.

Within 10 minutes the ambulance was at their doorstep. But by then Mary was on the ground mumbling, not responding or following any commands. In the emergency room, she had a CT scan of her head, she had a large pool of blood on the left side of her brain, which squished the brain to the right side and the brain tissue was being pushed down as well.

She was immediately transferred to the surgical unit where a neurosurgeon drilled a hole in her skull. And they placed a tube in the space and drain the blood. By this time, Mary was intubated because her breathing centers were failing in the brain, and she couldn’t hold her airway open. After some conversation with the husband, it became apparent that Mary had been a heavy drinker at some point, and had liver problems which affected her coagulation. And she had a bleeding disorder, and that may have contributed to the brain bleed. And that brings us to the topic of our discussion today, which is brain bleeds or cerebral hemorrhage and the diseases of the brain blood vessels. It’s remarkable that the vasculature of human brain is so phenomenal. There are over 400 miles of total vasculature in the brain.

Dean Sherzai (04:22)

I know I mean, 400 miles of capillaries, if you connect them end-to-end. Somebody did the math on this. And this is important. This is an important topic because it’s much more common than we we would think. And there’s not just one type of brain bleeds disorders. There are many different types and people have different proclivities, different tendencies, different risks at different ages. And often it’s missed.

And often if it’s understood or if it’s found it’s found too late. Many stories are similar to Mary’s we hear or we see in the emergency room, we you and I, ourselves have seen this, often the period of time from the time of head trauma to the time where it’s discovered as symptoms manifest vary anywhere from immediate all the way to even a day later, or even months. We call it chronic subdural. And that happens in elderly who have atrophied brain and there’s the slow bleed, and accumulation of blood under the skull for the minimalist thing sudden movement.

So but there’s a huge range of bleeding disorders. And today, we wanted to kind of talk about this concept, which is prevalent but unknown. And the important factor here is that to be aware of some of these, we can avoid the consequences, the long term consequences because often the long term consequences is death. And you’ll hear all these statistics that we’ll go over.

But if it’s caught early, it’s absolutely the opposite. You could there could be abatement, stoppage of the progression, it could be recovery, significant or complete recovery depending on how bad the bleed is. But it’s good to know these disorders. As Ayesha said, the brain is the most vascular organ in the body. I mean, we’ve said this multiple times when we were at UCSD, we saw this pathologist, which showed us tissues where they’ve denuded or gotten eliminated all the other tissue except the blood vessels, and all that’s left is blood vessels. Usually, these are imaging, reconstructions.

And it’s remarkable to think that there’s anything else because it’s all capillaries. And the reason is because we have 87 billion neurons and hundreds of billions of glial cells. And each of these need capillaries close enough to transfer nutrients and oxygen to them. So it’s everywhere ubiquitous in the brain. And that’s why 25% of our body’s energy is used in the brain. And that’s why a significant portion of oxygen is utilized in the brain as well. So with that said, let’s go over some of the epidemiology, some statistics. And then we’ll go into what they look like, how to identify them, and what we can do as far as prevention is concerned.

Ayesha Sherzai (07:15)

Absolutely. So I think it’s important to start with definitions, because the term brain bleed on which is also known as intracranial hemorrhage is a very, very broad term. What first of all, there are two main areas where bleeding can occur in the brain. So the bleeding can occur either within the skull, but outside of the brain, and it can also occur inside the brain tissue.

And so these areas are further divided. The brain has three membranes, which are also known as meninges. And these membranes are arranged between our skull, the bony skull and the actual brain tissue. And the purpose of these meninges is to cover the brain to protect it, and it serves many different functions as well. Now the bleeding can occur anywhere between these three membranes. The three membranes are called dura, arachnoid, and pia mater.

Now, the different kinds of bleeds that we hear about are epidural bleed, which essentially happens between the skull bone and the outermost membrane layer, the dura mater, and we have subdural brain bleeds, subdural bleeds, which happens between the dura mater and the arachnoid membrane and that’s where a lot of the arteries are. Correct then that’s the one that you were actually talking about that happens mostly in elderly people chronic subdural hematomas happen within, you know, days, two weeks after a very minor injury in elderly people.

And they happen to people who tend to have either atrophy of the brain, or say for example, if they’re on some sort of blood thinners like anticoagulants for atrial fibrillation, for people who actually have coagulation problems, whether it’s because of drinking excessively, or some liver disease, or many other medical conditions can contribute to it as well.

Then we have subarachnoid bleeds or subarachnoid hemorrhage. And this happens between the arachnoid membrane and the pia membrane. So it’s on the inner side of the brain layers. So these are the kind of bleeds that don’t happen inside the brain tissue, but basically, between the skull and the brain. And then we have the bleeds that occur inside the brain tissue and these are called intracerebral hemorrhage, or hemorrhagic strokes as well.

Now, hemorrhagic strokes essentially make up for about 13% of all strokes. If our audience listened to our previous episode, we know that most strokes are ischemic strokes, which is as a result of a clot or some impediment in the blood flow of the brain.

You know, not getting oxygen and nutrients to a particular part of the brain. But intracerebral hemorrhage is when there is damage to the blood vessels inside the brain tissue. And that causes release of blood into the brain tissue.

The majority reasons for death related to stroke, actually are attributed to hemorrhagic strokes, it’s quite fatal, it causes a lot of disability, even if people, you know, survive the intracerebral hemorrhage, subarachnoid hemorrhage as well. And the reason is because it almost acts like a tumor or a space occupying lesion that happens very quickly. And it presses on very vital parts of the brain causes damage to say, for example, respiratory centers or the centers of the brain that respond to our, you know, autonomic nervous system or the cardiovascular system.

Dean Sherzai (10:56)

And in this case, it’s not something that you can take out like clot, because of the arteries clogged, you can take out the clot either with a clot busting drug or with instrumentation, right with a with a tube that goes through your arteries and then actually retrieve the clot. In this case, the arteries actually ruptured. So the bleeding is going on, and the best you can do is stop further bleeding. But the damage is done already. And the key is to make sure that there’s no further damage.

And the damage that’s done is fairly extensive, because it’s not just the artery that burst. It’s the tissue that’s not getting oxygen and the tissue that’s actually being pressed as well. And here’s the press part. If it’s pressed enough and pushes one side of the brain to the other side, you can actually have episodes where breathing is stopped. Or if it pushes the brain down, it can actually push on the centers of the brain, the brainstem, we’re breathing and the basic functions of living are being done. So those are stopped.

So that’s why bleeding is a lot more fraught with a permanent disability and potentially death.

Ayesha Sherzai (12:06)

Absolutely. Now, who is affected by brain bleeds? Well, it depends. You know, there are various types of intracranial hemorrhages that happen in people at different ages. Although cerebral hemorrhage, you know, in the kind of bleeding that occurs anywhere inside the brain, and hemorrhagic strokes are most common in older adults, they can also occur in children. I mean, we have an entire segment in neurology on pediatric strokes or pediatric hemorrhagic lesions.

So you can actually see different age groups being affected by hemorrhagic strokes in different ways. But the majority of cases that we see as adult neurologists, they occur in older adults and in children, it’s usually not because of vascular risk factors, but because of some anomalies in blood vessels. And these could be because of things like and AVM arteriovenous malformation, or it could be some aneurysms. Other possible causes are things like some brain tumors, infection or septicemia, or infection in the system of the baby.

Dean Sherzai (13:23)

…or prematurity, premature intraventricular hemorrhage is fairly common in premature birth.

Ayesha Sherzai (13:29)

Absolutely. And those are as a result of either direct or indirect trauma during birth. So these are, you know, some of the reasons that you actually tend to see it in the pediatric population. And the numbers are pretty, you know, I was surprised to see the numbers according to the National Stroke Association. A stroke happens in about one in 4000 live births, and children typically recover from brain hemorrhages, thankfully with better outcomes compared to adults because their brain is still developing and it recovers rather fast.

Dean Sherzai (13:30)

…and even functions are transferred to other parts of the brain.

Ayesha Sherzai (14:03)

Absolutely. A few statistics cerebral hemorrhage is accounted for about 13% of all strokes in the United States, and it’s the second leading cause of stroke. The leading cause of stroke is a blood clot or ischemic strokes. Ruptured brain aneurysms affect about 30,000 people in the United States every year AVMs or arteriovenous malformations are present in about 1% of the population. And about 2% of all hemorrhagic strokes are from an AVM every year.

Yes, let’s go over some of the causes of brain bleeds. So there are a number of causes and the first one seems to be head trauma. And that is usually seen in elderly individuals after say for example a fall, a car accident it seen in you know middle aged individuals or adolescents after sports accidents or any type of blow to the head. And it can range from very subtle bleeds that it’s almost difficult to see on a CT scan on an or an MRI, or large bleeds that essentially act like a space occupying lesion inside the brain. And you tend to see the effects rather quickly.

But you know, the symptoms also depend on the initial health of the brain. So you tend to see symptoms rather quickly in someone who has a relatively healthy brain that is not experiencing any atrophy or shrinkage. And the reason is, there’s not much space in the brain for it to kind of, you know, allow for the bleeding to occupy. So you, you get to see that very quickly. But in a lot of elderly adults who have a lot of space or some atrophy in their brain, even if there is some bleeding, you don’t tend to see a lot of symptoms, do you?

Dean Sherzai (15:51)

No, no, you don’t, because the brain has adjusted. So even if there’s movement, because the brain is smaller, shrunken, the movement is not going to press on any vital parts of the brain.

Ayesha Sherzai (16:03)

Absolutely. The second and I think this is something that the second reason is high blood pressure, high blood pressure is a major risk factor for hemorrhagic strokes. And the reason is, long term unmanaged or uncontrolled, high blood pressure can start damaging the inner linings of blood vessel walls, and it can cause blood vessels to leak or burst, or over time harden and then result in a potential, you know, aneurysms etc. So we see that quite often.

And that’s why from a public health perspective, I think managing blood pressure is one of the most important things we can do for reducing both the risk of ischemic stroke and hemorrhagic stroke.

Dean Sherzai (16:45)

I can’t emphasize this point enough that blood pressure management can affect so much of your health be at hemorrhagic risk, be at strokes in general, be at heart disease, be at cognitive decline, across the board, blood pressure management is probably one of the most important things we can do.

And no matter how much I speak about it, not many people actually follow the recommendations of doing at least once or twice a day blood pressure measurement, and recording it and following it over time. I’ve seen just this last week, at least a dozen patients who came in with blood pressures above 150, 140, 150, and actually a couple of them in the 180s and 190s.

And that’s that to me is a mini stroke, because you might not see the overt big stroke. But those small tenuous arteries are getting damaged. So that’s where one of the opportunities lies where you can definitely reduce the risk of stroke, vascular disease and dementia for that matter by managing blood pressure. And that’s the emphasis that we make in every clinic visit.

Ayesha Sherzai (17:54)

And as neurologists were actually trained to figure out when someone comes in with a stroke, when you look at their CT scans or their MRIs, you can almost always tell that the bleed is associated with high blood pressure, because it affects very particular parts of the brain.

So the inner, deeper aspects of the brain like the basal ganglia, or the pons, or the cerebellum are usually affected by hypertension. So the bleeds in those areas tells you that this person may have had either a very acute onset or a very quick increase in their blood pressure at that particular time, or they have had unmanaged blood pressure over a long period of time. So the location of the bleed can also tell you the reason behind the bleed. And then the next reason.

The next cause for bleeds, is buildup of fatty deposits in the arteries, or atherosclerosis, which is hardening of the arteries. So atherosclerosis is the term used for hardening of the arteries, larger arteries, and if it’s medium sized, it’s called arterial sclerosis. And essentially over time, the inner linings of the blood vessel walls the kind of get damaged with the deposition of plaques, and this can result due to unmanaged fat metabolism or high LDL for that matter, and even abnormal glucose metabolism.

So say for example, if someone has insulin resistance or unmanaged diabetes, this kind of a pathology can take place and over time, it thins out the blood vessels and it can burst and cause bleeding.

Dean Sherzai (19:39)

Not to be dire and trying to scare people but people don’t realize how tenuous our blood vessels truly are. Especially after 50 years 60 years of blood pumping through those arteries or arterioles a small arteries or capillaries for that matter, and especially if somebody has had blood pressure, even minor increased blood pressure. For years and years, those arteries are going to be really, in tenuous situation, they’re going to be rupturing or clotting off if we don’t take care of them.

And on top of that, you add high LDL, high cholesterol, the damage both as far as the accumulation of that material in the in the wall, as well as the physical trauma to the wall is just immense. And that should bring us a greater awareness of we are almost magical in our thinking, aren’t we, oh, we’re going to be fine. We’ve been fine for the last 40 years, 50 years, and it’s going to be fine.

Nope, the cumulative effect is one of just persistent trauma to those little arteries, and eventually going to they’re going to give up. But the good news is, there’s data that if you take care of the blood pressure, if you take care of the cholesterol, that is significantly reduced.

Ayesha Sherzai (20:57)

Absolutely. And we’ll talk about the association between LDL and cerebral hemorrhage in a few minutes, because that’s also a very, very interesting point that has become almost a debate when it comes to management of vascular risk factors. In any case, moving on to the next one, which is ruptured cerebral aneurysms, or aneurysms are essentially weak spots in blood vessels, that kind of balloons out. And then over time, if there’s a lot of hemodynamic pressure, and there’s high blood pressure, and you know, conditions in the body that affects the inner lining of the artery, they essentially burst and they start bleeding.

Dean Sherzai (21:39)

And those are fairly common. And large percentage of population, one in 50, or in some series, they say is one in 20, which is one to 5% of the population have aneurysms. Now, not all of those burst, not all of those bleed out. But that means that those are people who are at risk.

Now, if you are one of those people who have the aneurysm, and you have high blood pressure and cholesterol, you’re going to be much higher risk of bleeding. And those usually happen in particular areas. And we also almost know for a fact that as soon as if somebody has a bleed in that particular area, what kind of deficits they will have, because the particular function of the brain is directly related to the location.

Ayesha Sherzai (22:23)

So far, you know, if somebody has an aneurysm, and you know, that’s a pretty large number, the estimation is that 6.5 million people in the United States have an unruptured brain aneurysm. That’s a lot of people. And so the size matters as far as the decision of doing something about it. So typically, if it’s less than five millimeters in size, neurosurgeons don’t really do much about it, depending on where it is. And if there’s any other risk factors.

And when somebody is detected to have an aneurysm, and that usually is essentially it’s like an accident, you know, you’re looking for something else. And then you find out that you have an aneurysm. And what neurosurgeons and vascular neurologists do, they keep an eye on it by imaging the patient on a regular basis, maybe annually, maybe every two years, depending on the size.

And you know, over time making a decision, if there’s something necessary to do, but it’s important for people to be aware of that and get themselves checked if they have an aneurysm. And obviously, whether you have an aneurysm or not managing vascular risk factor that is critically important for prevention of stroke in general.

Dean Sherzai (23:30)

Sometimes, though, even prior to full blown bleeding, when there’s the Sentinel bleeds, where the aneurysm is actually kind of leaking then it creates these headaches, or what’s called meningeal irritation where the neck feels tight. Now, everybody who’s got neck tightness shouldn’t feel like they’re having an aneurysm. I’m just saying that those are some of the signs are, or headaches, terrible headaches.

The other thing that can happen is if these aneurysms are in particular areas, let’s say next to the ophthalmic artery or next to the visual centers, people actually if it’s large enough, it can press on visual lines of communication, and people can actually lose their sights. Yeah, so that is another way. But those are rare, you would be lucky if you get that.

And the important part of this is that if you detect it early enough, there’s a lot people can do. First of all, if it’s small, you just observe it over time. And if it gets big enough, the surgeons can go from outside and clip the artery with these special clips that closes it off. Or they can go through the artery and then go into the aneurysm if it’s amenable and put coils so they actually clot forms inside that. And that basically makes the aneurysm meaningless. It’s no longer in danger. So there’s a lot that can be done, but you have to know what you’re looking for.

Ayesha Sherzai (24:56)

Right. Absolutely. All right, the next one cause or the next reason for brain bleeds is buildup of amyloid protein within the artery wall of the brain. And I think we talked about cerebral amyloid angiopathy, a little bit in the previous episodes. But this essentially is a condition where there is excessive deposition of amyloid in the arterial wall. And we tend to see either small little microbleeds all over the brain looks almost looks like a Christmas tree.

Yeah, a reverse Christmas tree there are these dark spots all over the brain. And then sometimes there is a massive bleed inside the brain. And the typical questions that we get in our neurology boards is an elderly person with some mild cognitive impairment or some memory problems comes in with a massive bleed. What could the reason be? And it usually is amyloid angiopathy.

Dean Sherzai (25:50)

Absolutely. And it’s often seen in older population, as you said, and the way to detect those, although that’s very difficult is to know ahead of time that there’s amyloid deposition. And when you see these little micro vasculature hemorrhages, or micro hemorrhages early on, that’s when you actually start managing and the only management at this point is blood pressure managment, there’s no medication, more aggressive blood pressure management to make sure that these cumulative amyloid deposition does not become a massive bleed, because of pressure, blood pressure. And that’s the knowledge that will help you avoid those massive bleeds.

Ayesha Sherzai (26:31)

We talked about arteriovenous malformation, which, is a leak from abnormally formed connections between arteries and veins. And then we have bleeding disorders, you know, like people who have some coagulopathies, whether it’s a genetic coagulopathy, where they are either missing a fraction of an enzyme, or they’re completely missing an entire process where clotting products and bleeding processes are not controlled very well. So whether it’s a small little bump against their shin, or maybe even a whiplash injury can actually result in massive bleeds in the brain.

Dean Sherzai (27:10)

Correct. I mean, there are two, I’m oversimplifying the bleeding cascade or cloud coagulation cascade. But if you are, if you’re having these little bleeds on the skin, they call it petechiae. That’s usually related to platelets. And people can actually, that can actually affect the brain as well, yes. But then the deeper tissue bleeds are as a result of the coagulation pathway, which is pretty amazing to see these, you know, these proteins, that one actually affects another and on and on 12 different proteins that affect each other until you get coagulation. And anywhere in that pathway.

If one of those are genetically off a person has a higher likelihood of bleeding or clotting. Factor Five Leiden, protein C and S and all these disorders that are fairly common, and different populations have different proclivities for these bleeding disorders. So that’s something to be aware of as well. That if you have a family history of bleeding disorders, that matters, because that affects the kind of pills you can be on the kind of medications you can be on how you should be observing your clotting factors, how you should be observing your blood pressure and everything else, including the food you eat.

Ayesha Sherzai (28:21)

Absolutely, absolutely. All right. And obviously, you know, people who are on anticoagulation, or anticoagulant therapy on blood thinners can also be at high risk for brain bleeds. The next one is brain tumors. Now, brain tumors that especially the ones that press against the brain tissue can cause bleeding. Sometimes, brain tumors have specific blood vessels, you know, because when they grow, the tumor itself starts having very elaborate vasculature.

And these blood vessels, because they’re not supported very well by the structure of the tumor, it can start bleeding inside the tumor, and eventually outside causing a lot of pressure against the brain metastases or seeding of cancer cells from other parts of the body. Like for example, the primary cancer is in the kidney, but it actually seeds in the brain, it can actually cause bleeding, it’s been associated with increased risk of bleeding, and melanomas, skin cancer can cause a lot of bleeding in the brain.

Dean Sherzai (29:26)

Not all metastases are associated with brain metastases are bleeding. For example, prostate cancer is not associated but melanoma and kidney are fairly well associated.

Ayesha Sherzai (29:37)

Definitely. The other lifestyle related risk factors are smoking, heavy alcohol use, use of illegal drugs like cocaine or methamphetamine have been associated with intracerebral bleeds. And most of these are either related to, you know, constant harm or current constant damage to the blood vessels or sometimes a massive change in blood pressure with regards to drug use whether it’s cocaine or methamphetamine or some other ones, it usually has to do with massive changes in their blood pressure, or arrhythmias development of arrhythmias but in bleeds specifically is because of blood pressure changes.

So we tend to see that as well. Now we see a lot of brain bleeds related to people who have smoked for a long time.

Dean Sherzai (30:26)

Smoking is probably one of the more common and then alcohol can be both directly, but more often indirectly, through how it affects coagulation pathway, and how it affects the liver. And through those pathways, you see a lot more bleeding disorders.

Cocaine obviously is a vasoactive drug, it affects the vasculature significantly. So that’s seen fairly commonly as well, bleeding in the brain as a result of cocaine and methamphetamines.

Ayesha Sherzai (31:00)

Pregnancy itself can be a huge risk factor for brain leads, or any conditions that is related to pregnancy or childbirth, like eclampsia or postpartum vasculopathy can result in brain bleeds and even in the baby’s you know, neonatal intraventricular hemorrhage is one of the reasons or one of the outcomes of having some sort of coagulopathy if the mother has coagulopathy, it can result in a neonatal intraventricular hemorrhage as well.

Dean Sherzai (31:29)

Well, eclampsia has two ways that it increases bleeding the protein I mean, by definition, a clamp says when the protein there’s protein loss in the urine in the women and high blood pressure, and those two combinations are definitely a perfect storm for bleeding disorders in the brain or in the body in general.

Ayesha Sherzai (31:49)

Now, it’s difficult to actually figure out you know, who can develop eclampsia or preeclampsia or not. But from my understanding, if a mother has appropriate blood pressure, does not have insulin resistance or diabetes is not overweight and is generally healthy.

The risk of developing preeclampsia eclampsia and potential brain bleed is on the lower side, correct? Absolutely. All right. And then there are some other conditions that are related to collagen formation, abnormal collagen formation in the blood vessels. And what it does is it kind of weakens the walls of the blood vessels, and it results in rupture of vessel walls. Those are very uncommon.

Dean Sherzai (32:39)

Right, more genetically orientation.

Ayesha Sherzai (32:41)

Yes and it usually represents or manifests earlier in life, with, connective tissue disorders, whether it’s skin, joint, eyes and some sensory problems. So it’s not something that kind of happens all of a sudden, but people tend to have some manifestations of it earlier in life as well.

Dean Sherzai (32:42)


Ayesha Sherzai (32:45)

Let’s talk about some of the symptoms of brain hemorrhage. Now the symptoms can be varied, because it just depends on where and the extent affected.

Dean Sherzai (33:11)

But if it’s not massive, because of its massive, it’s usually fairly quickly goes to coma, and potentially death. But if it’s not massive, usually severe headache is especially subarachnoid and things that irritate the arachnoid usually result in headaches.

Ayesha Sherzai (33:30)

The interesting thing is the brain itself does not perceive pain, even though it is used for us understanding pain and pain mechanism and it’s processed there, but the brain tissue itself does not have any pain receptors.

That’s why you know, when you see in those movies where the patient is awake, and the neurosurgeon is kind of, you know, touching the brain and doing their surgery, patients actually don’t feel anything most of the pain receptors are in the meninges and specifically the subarachnoid area.

Dean Sherzai (34:01)

Yeah and usually when they have the headache, they say it’s the worst headache of my life. And as soon as we hear that, it’s a CT scan. Well, any bleed, any signs of bleed, any possibility of bleed, should have a CT done.

Ayesha Sherzai (34:13)

Oh, the term thunderclap headache is used. Exactly. That is usually a a notification that we have to do some neuro imaging to make sure that there’s no bleeding.

Dean Sherzai (34:28)

Now, a lot of times with the CT scan, you see a bleed fairly commonly at CT, if there’s anything CT is good for its bleeding and tissue damage, skull damage, but sometimes you miss it because the bleed is not large enough to be missed. So that for you, if you still suspect it because the meninges are irritated, they feel neck tightness and they have a headache or something like that then you still do a lumbar puncture, which is this needle that goes in the lower spine drawers, the cerebral spinal fluid, the spinal tap, and if there’s blood there, then it’s most likely a bleed.

So that’s, what tells you that there’s a bleed. And the importance of this is that if you even suspect that you might have a bleeding disorder, don’t hesitate to go to the emergency room quickly. This might be an overcall or overshoot for a lot of people.

But I think the cost benefit of the fact that if somebody is at risk, they have history of high blood pressure, they have history of aneurysms, they have had family history of aneurysms, they’ve had a head trauma, that’s bad enough that now they’re experiencing some symptoms, if they are on the older side, and if they had head trauma, or any of those things, that I think that your first call should be to check it out, make sure that it’s not a bleed, because the consequences are often fatal. And if not, it’s quite dire and irreversible. So that’s what needs to be done.

Ayesha Sherzai (35:51)

As neurologists we were always trained to take headaches seriously. And to kind of err on the side of doing more than less when it came to differentiating between a headache that was just the general headache versus one that was associated with a bleed.

There were so many occasions where we’ve heard horror stories from patients saying they had a headache, they went to their doctor and they were sent home with some Tylenol or some you know, over the counter pain medication.

And the pain never went away. And they were forced to go back to the emergency room within a few days. And eventually somebody took it seriously did a CT scan. And there it is. There’s a subarachnoid hemorrhage sitting right there. That is an extreme case, but it has happened. Have you heard about it?

Dean Sherzai (36:36)

Oh, often, often.

Ayesha Sherzai (36:36)

I’ve heard a lot about especially young healthy people who don’t necessarily know whether they have vascular risk factors or not and they have a subarachnoid hemorrhage. And they just live with this horrible, horrible headache for days and days.

And we’ve also heard about some horror stories of things kind of, you know, taking a completely wrong turn and getting worse. So we always have to make sure that the get a CT scan. And even if the CT scan doesn’t show anything, a spinal tap is absolutely necessary, whether it’s in the emergency room or in the clinic.

The next symptom that is quite prominent is sudden neurological deficit, it could be weakness, it could be numbness, it could be paralysis of one side of the body, of the face, it usually is focal, which means it affects one part of the body instead of all parts of the body because the bleed being on one part of the brain, whether it’s on the left side, or the right side affects that particular part. So we do see and do check for focal neurological deficits.

Dean Sherzai (37:41)

Absolutely. So the the most important thing here is to detect any change from baseline. Any change from baseline, if you suspect risk, what we did today was kind of lay out some of the risks. The risks are blood pressure, the risks are high bleeding, and all of these things and, and I want to I want us to kind of take a pause and go over this list that Ayesha is gonna go over the entire list.

And make sure that you’re aware of this, because it’s completely treatable. In fact, many of the bleeding disorders are surgically amenable and responsive if we catch it early enough.

Ayesha Sherzai (38:22)

Absolutely. So we have nausea and vomiting, confusion, dizziness, seizures, because again, you know, irritation of the brain can result in seizures, difficulty swallowing, loss of vision, not being able to see things properly, loss of balance or coordination, stiff neck, like you said, our sensitivity to light and sound, abnormality and speech, slurred speech, difficulty reading or writing or understanding people and any change in level of consciousness, especially if the bleed is affecting the brain stem, and sometimes trouble breathing and abnormal heart rate.

So, you know, it’s quite varied, but this is the main list of the manifestations of a brain bleed. Correct. All right, so let’s talk about this diagnosis. We did say that it’s very important for them to be examined, any change in baseline is detected. The first and the foremost thing that people usually do is neuro imaging and CT scan is very fast, takes about five to ten minutes to do a CT scan.

And it has a very high sensitivity of detecting bleeding but we also have magnetic resonance imaging or MRI or MRA Magnetic Resonance angiogram which looks at the arteries and the veins in the brain. And these can actually help us determine the location, the extent and sometimes even the cause of the bleeding depending on where it’s coming from.

Spinal tap to examine the service spinal fluid that surrounds the brain. And in some cases, we tend to do conventional angiography which essentially means that you know there is puncture to a major artery and usually is either in the groin or in the arm, and then through a coil you’re supposed to actually go into the brain, and then there are films or X rays taken that can help us identify lesions like aneurysms or arteriovenous malformations. Sometimes even during the diagnostic procedures, neurosurgeons, or vascular surgeons tend to even start the treatment.

Dean Sherzai (40:20)

They think it’s urgent, and it needs to be addressed right there, they can actually start it right then.

Ayesha Sherzai (40:24)

Yeah, so whether it’s clipping or coiling or injecting some glue to hold that aneurysm or the AVM stable, it is done right there and then, and as far as other treatments are concerned, we talked about evacuation of the blood from the brain.

The common thing is drilling holes into the skull, what’s called burr hole. And then they place in a tube called the EVD extraventricular device where it actually starts draining some of the blood to the outside to relieve some of the pressure in the brain. And there are times when they actually remove part of the skull to allow for the brain to swell and expand, it’s called craniotomy. And it remains out and cut for days to weeks, sometimes even months.

Dean Sherzai (41:10)

It’s an amazing thing to watch.

Ayesha Sherzai (41:12)


Dean Sherzai (41:13)

The brain, you can actually see the movement of the brain tissue. But the reason they had to take that part of the brain out or the skull out, is because if they try to drain the blood through a tube the pressure is so rapid that actually brain tissue can go through it. So you have to remove a sizable chunk of the skull, so that the brain can actually swell out and relieve the pressure.

Ayesha Sherzai (41:35)

And multiple studies have shown that people actually it reduces mortality, it reduces significant amount of disability, when that is done, it’s a very scary thing for family members to see, you know, part of their loved ones brain just bulging out of their head.

But it is a life saving procedure. And it has an amazing, amazing things. And then, depending on the reason, or the cause of the bleed, or multiple things that can be done reversal of anti coagulation, giving them FFP or blood products to make sure that the coagulation cycle comes back to normal, making sure they get enough blood and fluid so that they don’t have a cardiac arrest, making sure that whatever lesion that is causing it in many cases, for example, in brain tumors, you know, sealing or getting rid of that space occupying lesion, there are multiple things that can be done at that particular time.

But as far as intracerebral hemorrhages related to unmanaged vascular risk factors are concerned, a big big portion of them can be prevented. And we talked about the importance of blood pressure management and cholesterol management. And those are the things that we often see, because of just the sheer number of patients presenting with those kinds of conditions.

Dean Sherzai (42:54)

What about low cholesterol levels, which we hear quite often.

Ayesha Sherzai (42:58)

Right, so, you know, I think there’s no doubt that lowering cholesterols, LDL cholesterol let me be very specific has been associated with better cardiovascular outcomes. So it can prevent, you know, it’s used for both primary and secondary stroke prevention.

But there’s some data from epidemiological studies and clinical observations that showed that when people have very low LDL, so for example, people who have less than 70 milligrams per deciliter of LDL, especially among East Asian men, they tend to have higher risk of hemorrhagic strokes. Now, this data has been, you know, kind of replicated in multiple studies.

And it’s mostly seen in East Asia, Asians, specifically in men. The mechanism is not very clear, they haven’t really been able to understand as to why that happens. But there are some hypotheses. And it’s essentially based mainly on the fact that people need an adequate lipid level for maintaining normal membrane fluidity and vessel integrity. And that anything lower than 70 milligrams per deciliter could potentially affect that process. And it could make the blood vessel walls weaker, but it’s not very clear…

Dean Sherzai (44:22)

…because we usually ask for people to be lower than 70 yet this is for people who are susceptible, this is for individuals that are susceptible for bleeding or a particular category.

Ayesha Sherzai (44:34)

Right, right. And so, some groups have come up with a concept that is, noted as the double hit phenomenon or the double hit model, which essentially says that if people have very low LDL, and on top of that, they have other structural changes or other risk factors, say for example, high blood pressure or initiation of anticoagulation in them or initiation of antiplatelet agents like aspirin or Plavix or these other medications, the low LDL and then the other risk factors significantly affect the inner linings of the arteries, and they can put people at a higher risk for having hemorrhagic strokes.

So that’s just a concept and a theory again, we need more studies to look into it more data. And it hasn’t really been seen outside of Asian population. So we’re not really sure what that is. And this doesn’t mean that we should stop lowering LDL for primary and secondary ischemic stroke prevention or for cardiovascular health. But it essentially points to the fact that it’s, obviously we need more data. And it’s very important to look at the entirety of a person’s risk factor before deciding whether they should be on a particular type of medication or their LDL needs to be lowered significantly.

Dean Sherzai (46:01)

Absolutely, beautiful. So what we were talking about here, the description of the patient, Mary, what diagnosis would we give her?

Ayesha Sherzai (46:13)

So Mary’s seemed like she had, you know, she definitely had trauma, and she started bleeding. And there was a period where she felt pretty okay. And you tend to see that in epidural hematomas, where, you know, initially when people have head trauma, they kind of feel dizzy, they may even lose consciousness for a little bit.

But then there’s a lucid period. And that lucid period could be minutes, hours to sometimes even up to a day. And what happens is the bleeder of blood vessels or whatever damage that has been done slowly and gradually starts bleeding and bleeding, bleeding, and it presses against the walls or the the side of the brain.

And patients start having manifestations of that bleed or start experiencing symptoms when there is significant amount of compression of the brain where they lose consciousness and they have focal neurological deficits. So I think she had an epidural bleed.

Dean Sherzai (47:08)

Yeah. And then we we’ve known many people in the media that that we’ve heard about that had similar one of them is Liam Neeson, his wife. Richardson. Yeah. That was, yeah, she was a skier. And she’ll, so she was Natasha Richardson. She was skiing.

And she fell just normal fall and hit her head and she was fine. She came back home. And then within hours, she became more somnolent and unresponsive. And she started having a bleed in the brain and she passed away. And that was one of the cases that was shocking to everybody that this she was young and vibrant, and active she was skiing. And yet a one little trauma that was not recognized early enough ended up taking her life.

And so that’s, that’s why it’s something that’s treatable avoidable. And that was just one version. We talked about the epidural then, you know, the aneurysms, one can identify them early enough, the the other kind of bleeding disorders that we have, and then of course, the big ones, alcohol, cigarettes, cocaine, blood pressure, and you know, these kind of things.

Ayesha Sherzai (48:20)

Let’s talk about the more common ones, you know, like people who have unmanaged cholesterol or if they have diabetes, or if they’re not eating a healthy diet, or if they’re not exercising, these factors do matter in and, you know, multiple studies, when people live a healthy life, they have lower risk of both ischemic and hemorrhagic stroke.

So there’s a lot one can do, obviously, I mean, there are some conditions that, you know, you didn’t have to do anything with it. Like for example, arteriovenous malformation, you were born with it, but for the majority, there’s a lot that one can do to prevent this devastating disease

Dean Sherzai (48:52)

Or their group of diseases for that matter.

Ayesha Sherzai (48:54)

Absolutely, this was really helpful.

Dean Sherzai (48:57)

I think so. I think that this should raise some awareness and we’d love to have some conversations about this with the audience, and more importantly, you know, spread the message.

Ayesha Sherzai (49:08)

Thank you for listening.

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