Miseries of strokes or brain hemorrhages and their impact in Kashmir

A stroke is a life threatening catastrophe and a devastating disabilityfor a patient and its family. A lot of panic and hopelessness enshrouds the family as soon as they learn about thediagnosis, prognosis and its complications.

What is a Stroke or a Brain Hemorrhage?

Stroke or a Brain hemorrhage means ‘bleeding in the brain’, that is the blood flowing in the lumen of a brain vessel, artery or vein,oozes out due to prick, cut, burst or spontaneous rupture within or from outside thebrain tissue so that the neural tissue is devoid of blood supply and is also pressurized by the weight of the volume of the oozed blood (clot) and the subsequent brain edema (water-loggingof the brain) around the hemorrhagic area. Let us be aware that the brain hemorrhage or stroke is one of the several types ofintra-cranial (inside-head) hemorrhages which occurby two ways, either insidiously/spontaneously or due to external interference like trauma to head resulting in many different types of intra-cranial hemorrhages. But the brain hemorrhage or the hemorrhagic stroke is caused only by the spontaneous/insidious causes like uncontrolled high blood pressure (hypertension) or rupture of a pre-existing aneurysm (segmental arterial saccular or fusiform or blister dilatation) andbleed in an arterio-venous malformation etc.

Physical and Chemical Design of Brain

Though brain may be an emotional ocean chemically but it has a physical design. The brain is a semi-solid pinkish-grey dough-like structure, completely occupied by the vascular-arborization, inside the head-bone, cranium. It is enveloped by the three coverings, the outer tougher, middle cobweb butthe inner delicate membrane isglued to the brain. The space, between the outer and the middle coverings, is potential but usually obscured called subdural space.However the space between the middle and the inner coverings is always open and is called the subarachnoid space. The brain water (cerebrospinal fluid or CSF) is found in the subarachnoid space and it flows over whole brain on all the sides, its base and inside the brain thereby forming water troughs, channels and caves called sulcii, fissures, cisterns and ventricles through which run the blood vessels. These vessels are very different in behaviour than non-brain body vessels in their reaction to the same stimulii like CO₂, out-of-lumen blood and O₂ causing dilatation and narrowing which increases or reduces the blood supply to the brainthat may result in the brain damage called hyperemia, edema, vasospasm, ischemia, infarct etc.Brain is divided in upper and lower storeys. The upper one has two hemispheres, each made up of many lobes. The lower brain also has right and left lobes with a central stalk, called brain-stem, connecting it with the upper brain. The brain lobes consist of brain tissuewhich comprise of billions of pure brain cells (neurons) supported by the supporting brain cells (neuroglia) in the form of hundreds of lobules and nodules (gyrii) separated by the shallow or deep troughs (sulcii). The sulcii carry brain water (CSF) through which run the blood vessels just before entering the brain tissue to supply it. Each brain tissue holds a name for the function it performs like speech area, visual area, hearing area, face area, lip area, thumb area etc. A particular brain area affected by the hemorrhage willaffect a particular function which it represents. Given all the above description, the biological behaviour of the brain appears to be more chemical than physical, that is why the ‘chemical brain’ carries out millions of emotional, cognitive, abstract and physical functions every second in the availability of thousands of neurotransmitters(chemicals).

Origin and types of strokes (brain hemorrhages)

These brain hemorrhages originate spontaneously, internally and insidiously, without any external force, due to rupture of a diseased artery or an abnormal vein outside or inside a brain tissue. There are three types of hemorrhages by the location of rupture like subarachnoid, intra-parenchymal (intra-cerebral) and both may be combined together.When the bleeding occurs just outside the brain tissue,that is inside the sulcus, within the brain water–the subarachnoid space or a cistern- before the vessel enters the brain tissue, the bleeding is called spontaneous subarachnoid hemorrhage (SAH). The causes for this type of brain hemorrhage are the rupture of an aneurysm, bleed in an arterio-venous malformation (AVM), rupture of a diseased artery likely angiopathic (atherosclerosis-unlikely) due to hypertension (high blood pressure>160/90mmHg) and many times a cause may beunknown. When the bleeding originates within the brain tissue itself, it is known as intra-cerebral hemorrhage (ICH). The cause of this hemorrhage is primarily uncontrolled hypertension (high blood pressure) and also diseased vessels, angiopathy, within the brain tissue. Sometimes the bleeding due to rupture of an aneurysm or an AVM may solely occur inside the brain tissue as an ICH. Many times the SAH may extend itself into the brain tissue due to volume-pressure dynamics to form a combination of SAH and ICH together or vice versa can also occur by extension of an ICH into ventricles and subarachnoid space. However which vessel, normal or diseased, and at what level of high blood pressure it ruptures is still unknown. The blood pressure recorded in the first instance, in the hospital or outside, after the symptoms of brain hemorrhage appear, is not the true blood pressure at which the hemorrhageoccurredbutthis recording is only the blood pressure reading that appeared due to the reaction of thecerebro-cardio-vascular axis after the hemorrhage.

Locations of Strokes (Brain Hemorrhages)

The subarachnoid hemorrhage (SAH) becomes quickly wide spread all over-and-under the brain, away from its origin, through the brain water (CSF) to settle in cisterns, fissures, sulcii and ventricles as semi-solid clots. Since the bleed is from the vessels anywhere along their course in subarachnoid space, it usuallyspreads to the whole brain along the brain water. However, occasionally SAH may become ICH at the site of origin due to aneurysmal direction, burrowing and adherence to the brain.The patient immediately looses consciousness and undergoes even heart(cardiac)-arrest only to revert back spontaneously in most of the cases. The hemorrhage is picked up by the plain CT scan as a diffuse spreadof bleed at the base and side bays of the brain. While as the location of an intra-cerebral hemorrhage (ICH) is restricted to the site of origin of the bleed only, that is brain tissue, but in many cases due to the larger size of the intra-cerebral hemorrhage (ICH) the pressure of the bled blood-volume gives vent into the subarachnoid space to become SAH or into ventricles to become intra-ventricular type. The ICH can occur at many sites in the braine.g.,any lobe of cerebrum, cerebellum, basal ganglia, thalamus, internal capsule, pons, medulla, mid-brain, intra-ventricular etc. The serious and life threatening complications arise from such hemorrhages like re-bleeding, hydrocephalus and infarcts which lead to the rise in intra-cranial pressure (ICP) and squeezing and sandwiching the delicate brain.

Stroke (Brain hemorrhage)Causes and Risk factors

The primary and most common causes of brain hemorrhages are the diseases and abnormalities of the vessels of the brain which burst like a balloon to let blood exude out. The hemorrhage can occur from the rupture of the pre-existing aneurysms andarterio-venous malformations(AVM) which could either be acquired or may exist since birth. The untreated and uncontrolled high blood pressures over longer periods of time can be a cause of devastating brain hemorrhage. The underlying cause of uncontrolled high blood pressure may be athero-sclerosis of the cardio-vascular system. The athero-sclerosis can affect even the vessels of the brain and weaken these to cause rupture anytime in future. The amyloid angiopathy, that weakens vessel walls, is another cause of bleeds which increases with aging and prolonged high blood pressure. The other well known causes of brain hemorrhages are hemophilia, sickle cell anemia, ingestion of blood-thinners and liver diseases. The risk factors for the brain hemorrhages in the Valley of Kashmir could be intake of intense salt-tea, smoking wet tobacco, ingestion of oily foods, lack of exercise, drug addiction, drugs for blood thinning, un-treated high blood pressure, cold remedies in winters etc.

Recognition of a Stroke (Brain hemorrhage)

Brain hemorrhage may occur in a person while sleeping, dreaming, sitting, standing, walking, talking, playing, working or exercising, where the patient falls/drops to the ground consciously or un-consciouslywith paralysis or without paralysis. The brain hemorrhages occur in all the ages, genders and everywhere in the world, more or less in the same proportions. The hemorrhage strikes a person like a ‘bolt from blue’ with severe headache like never before. Most patients lose consciousness before manifesting any other symptom and die suddenly due to massive hemorrhages. In moderate cases the patient might develop severe headache, vomiting, convulsions, stupor, paralysis of face, arms, legs, loss of speech etc. But headache may be the only symptom in many cases.

Stroke - Natural History and World View

Intracerebral hemorrhage (ICH) accounts for 10–15% of all strokes and carries very high morbidity and mortality rates that have not changed over the last 30 years. About 40% patients of ICH die in a month and up to 65% by the end of the year as studied by R Fogelholm, 2005 and Al-Mufti, 2018 - USA.The spontaneous subarachnoid hemorrhage (SAH) is associated with severe disability and high mortality rates despite a reduction in case fatality rates over the last four decades. Recent studies have reported mortality rates from 25% at pre-hospital to 18% in-hospital. Mortality also remains high after discharge from hospital, with rates of 40% within 30 days, 50% within 1 year and an elevated long-term mortality [Nieuwkamp et al -2009; Korja et al -2016; Lantigua et al -2015; Lichtman et al -2011; Huhtakangas et al -2011] in USA.However bothICH and SAHs usually complicate into frequent re-bleeds within first 2 weeks, intra-ventricular hemorrhages (IVH), hydrocephalus and/or vasospasm to produce fatal neurodeficits. The current studies show that the SAH carries a fatality rate as high as 65-80% within a month and one-third of this die suddenly within 24 hours without attending hospital.

Strokes and Kashmir Overview

The first study related to the brain strokes in Kashmir was published by SushilRazdan et,al from the SKIMS, Soura in an international journal way back in 1989, titled, “Cerebrovascular diseases in rural Kashmir”. The study says, “Kuthar valley in the Anantnag district of south Kashmir (North‐west India) was surveyed to ascertain the prevalence of completed strokes. In a population of 63,645, the survey was from July to November 1986; 91 cases of completed stroke were detected giving a crude age-specific prevalence of 143/100,000”.Although the first aneurysmal SAH, operated by the founder neurosurgeon of Kashmir, Prof. M. Afzal Wani in 1982, went un-reported, but the detailed study on SAH in the Valley of Kashmir was published as late as 2011 from the SKIMS, Soura in an international journal. The study titled ‘Subarachnoid hemorrhage in Kashmir: Causes, risk factors, and outcome’ says that, “the prevalence of aneurysmal SAH in ethnic Kashmiris is high owing to ‘typical diet and habit’ related risk factors and possible genetic factors. SAH, with an incidence of 13/100,000 per year, represents 31.02% of all strokes, a mortality of 36.60%, and good recovery of only 14.99% in Kashmir. The aneurysmal SAH at 54.35%is the commonest cause of mortality and morbidity. About 19.95% SAHs of all causes ended up in moderate disability. The severe disability occurred in 15.87% and vegetative state was found in 12.56% SAHs. A total of 36.60% of all SAHs died.

Treatment ofStrokes or Brain Hemorrhages

The brain hemorrhage is identified by a CT-scan of the brain and the underlying cause may be revealed by the brain-angiography called digital subtraction, MR or CT cerebral angiography. If the cause of SAH is an aneurysmal or AVM rupture, which is true in most of the SAHs, the treatment is either surgical clipping or Endovascular coiling/stenting or flow diversion of aneurysm and excision or embolization of AVM.

The treatment for the ICH is bimodal that is medical as well as surgical. The existing medical therapy is the prevention of hematoma expansion, blood pressure control and anticoagulation reversal which has been rewarded with improved outcome. The role of neurosurgery is still unclear due to the results of STICH trial (Mendelow, 2011) but the field is rapidly evolving. However the large sized ICHs causing fatal brain pressures and shifts still need surgical decompression to relieve the compression as a life-saving procedure. Although with moderate sized ICHs, the minimally invasive techniques like neuro-navigation, ultrasound and endoscopic assisted evacuation of hematomas can bepromising in selected groups.

Conclusion

Presently the overall outcome of the Strokes or brain hemorrhages in the World, even with all the modern advanced technical gadgetry-of-management, remains grim with high fatalities, severe disabilities and low good-recoveries. But the hope is rekindled with the better technical inventions and medical advancements in the future to have adefinitive treatment option at hand for the strokes.

Cite:Abdul Rashid, AfzalWani et al. Subarachnoid hemorrhage in Kashmir: Causes, risk factors, and outcome. Asian Journal of Neurosurgery 2011;6:57-71.

Dr. Abdul Rashid Bhat, is a Former Professor and HOD, Department of Neurosurgery, & Head Surgical Emergency, Sher –i- Kashmir Institute of Medical Sciences