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.

The Star Malaysia - Star2 - - Stroke Awareness -

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.

For more in­for­ma­tion, call 03-5639 1212.

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.

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