Not all brain aneurysms result in stroke but one should worry when the aneurysm grows to a significant size and when its walls are too thin, which are both measurable using medical imaging facilities.
is about 40%, so aneurysms are treated as early as possible.
“Our main motive of rushing treatment is to secure the aneurysm. Once it is secured, we can then move on to rehabilitation of the brain,” he explains.
If patients are conscious with a focal deficit when receiving treatment right after having a stroke, they can be moved to rehabilitation soon after. However, if patients are unconscious upon arrival, they will be monitored while their brain is allowed to recover. In the process of waiting for the brain to recover, rehabilitation begins.
“Even if a patient is unconscious in the intensive care unit (ICU), rehabilitation is already taking place. As long as patients are medically stable, rehabilitation can begin,” says Dr Ramesh.
Rehabilitation on unconscious patients involves manual manipulation of their bodies. They may be made to sit on a reclining chair meant for this purpose to stimulate their neck and trunk control.
According to Dr Ramesh, the idea of this type of rehabilitation is to stimulate the brain into functioning because the longer they remain prone in bed, the longer their situation persists.
He also explains the importance of having family members participate in a patient’s rehabilitation even if the patient is unconscious. In the ICU, it is the little things that can stimulate the patient that count.
To the patient, medical personnel at the hospital are all strangers but family members’ voices are familiar. In the ICU, anything that may trigger memory in the patient such as music they liked to listen to or movies they have watched before are played.
It is the memory that starts stimulating everything else into recovery.
Recovery is always subjective and depends heavily on factors such as the severity of the stroke and age of the patient.
According to Dr Ramesh, there stroke – A significant blood clot pressing on the brain causes pressure in the brain to increase and results in an oxygen deficit, ultimately causing cellular dysfunction that lead to a stroke.
Subarachnoid haemorrhagic stroke – A diffused bleed within the brain affects oxygen translation through the cells, also increasing pressure in the brain and causing a stroke.
Currently, there are two ways to treat a brain aneurysm – microsurgery and endovascular coiling.
Microsurgery involves accessing the aneurysm from outside the blood vessel through open surgery and clipping it off, while endovascular coiling (embolisation) involves feeding a coil through the blood vessel into the aneurysm, which will cause the blood in the aneurysm to clot, excluding it from intracranial circulation.
Deciding which option to employ depends on location of the aneurysm, size of the aneurysm, morphology of the aneurysm, proximity of important branches, age and medical background of the patient.
According to Dr Ramesh, families of patients tend to opt for the more minimally invasive option, which is embolisation but both options carry similar dangers and risks of mortality.
Dr Ramesh explains that, statistically, studies have shown that a grade 5 haemorrhage carries a 40% risk of mortality and morbidity but with modern advances in medicine, these statistics are fast becoming less relevant.
He observes that there is a false sense of security for patients and family alike that minimally invasive treatment carries lower morbidity. With advances in microsurgery of the brain, results of aneurysm surgery have improved by leaps and bounds.
Four months ago, he treated a patient with a grade 5 brain haemorrhage, the most severe score to grade bleeding in the brain, who has since recovered enough brain function to be mobile with assistance.
The patient, who prefers not to be named, is currently undergoing stroke rehabilitation in Ara Damansara Medical Centre.
“She is not the first case and will not be the last,” says Dr Ramesh, as he has seen many patients who come in with a poor grade brain haemorrhage and ultimately go home walking.
Rehabilitation is about retraining the brain and promoting neuroplasticity.
In the past, doctors predict loss of function from areas of the brain damaged such as expecting leftsided paralysis from right-brain damage. Today, with early rehabilitation and neuroplasticity, this loss of function can be regained.
Dr Ramesh maintains that managing an aneurysm stroke is not all about a successful surgical procedure. In tandem with intensive rehabilitation, the success is defined by functional patient outcomes and giving patients their independence back.
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Neuroplasticity is an important recovery factor in stroke patients, which is evident in one of Dr Ramesh's patients (pic) who has made amazing progress following her stroke four months ago.
Dr Ramesh Narenthiranathan.