The Hindu Business Line : Brain watch

Last November, after 21-year-old Priyangwada Perera had done a dance performance to celebrate Sri Lanka’s national day, she was scheduled to return to the stage and sing a song. “But while my friends were doing up my hair, I’m supposed to have complained — I don’t remember anything — of a headache, and within minutes I simply blacked out.”

What the Sri Lankan girl, studying English Honours at Miranda College in Delhi, didn’t realise was that she was having a brain stroke, induced by haemorrhage. She was rushed to the Sir Gangaram Hospital where Dr Shakir Husain, chief of services and consultant, Department of Stroke, attended on her.

“She had a blackout due to a defect known as aneurism in the brain artery, which is nothing but a ballooning in the artery; this happens due to constant pressure of the blood and the artery keeps expanding like a balloon and ruptures at some stage,” explains Dr Husain.

The result is haemorrhage; this is a catastrophic stage and in “half the cases the patients might not even reach a hospital.” But luckily for Priyangwada, at the programme organised by the Sri Lankan High Commission, a couple of Sri Lankan doctors working with the WHO were present. They immediately attended to her, and she was rushed to the hospital. “She was in a bad condition and required emergency care; actually the chances of her survival were very bleak. But we put her on the machine, settled her by giving cardiac and ventilator support. She improved, but was still critical,” he says.

In such situations it is important to establish if the bleeding has stopped, because, says the doctor, in about 45 per cent of such stroke cases, a second episode of haemorrhage could recur within 24-48 hours. If re-bleeding occurs from the aneurism, the patient could die.

An angiography done in Priyangwada’s brain showed a large aneurism or bubble of one cm. As it was located in a critical area of the brain stem, it had to be treated; rupture would have been fatal.

The neurologist explains that there are two ways of handling such cases. One, a conventional brain surgery where the skull is opened to approach the affected area of the brain under a microscope and then the affected part of the artery is clipped. “But it would have been a complicated surgery with a high risk, because in that particular location in the basilar artery, the chances of mortality in the most expert hands in the world is around 30-40 per cent. And the morbidity rate or the chances of a paralysis are about 40 per cent.”

GTC coiling

He opted for an alternative and relatively new intervention method known as GTC coiling. In this a catheter of three mm diameter is passed from an artery in the patient’s leg — as is done for the heart — all the way up through the heart into the brain artery. Through this a smaller catheter (0.75 mm diameter) is passed into the bubble. “Through this tiny catheter we deposit a special kind of detachable coil known as DTC coil; it can be pulled back if we don’t like the placement.”

But once the doctor is happy with the placement, a small current is passed through the coil to block the artery and close the bubble, to prevent it bursting again. “In surgery we clip it; with the coil we block the aneurism. In Priyangwada’s case, coiling was done and she made a remarkable recovery.”

The procedure took over three hours and costs about Rs 1.5-2.5 lakh, depending on the size of the bubble. The coil made of platinum is imported.

Dr Husain says this ‘coiling’ procedure is becoming popular and “in our hospital we do one every third day; “we use it on about 80 per cent of our patients requiring surgery to avoid a cut, and patients prefer it too.”

Risk factors

High-risk persons for strokes are patients with hypertension, diabetes, high cholesterol levels, obesity and smokers. “Last but not the least are those who work under a lot of stress and want to be high achievers; these are generally lean and energetic people.”

While statistics in India are not available, in the US about seven lakh brain strokes occur every year. “India should be at least four times higher, probably more,” is his alarming projection. Worse, doctors like him are seeing such cases more and more in younger Indians; “the so-called modernisation and lifestyle changes and tobacco intake in different forms — smoking, kheni, dant manjan, etc. are responsible”.

Strokes can be broadly divided into two categories; one is ischaemic stroke, due to a blockage in one of the brain arteries. About 85 per cent strokes are due to this reason and the rest due to brain haemorrhage as happened in Priyangwada’s case, “but in practice we see more of the latter.”

Quality of life

On the quality of life of stroke patients, the doctor says thanks to “our aggressive approach, we bring out these patients in a good neuro condition, so their quality of life is as good as earlier. The whole idea of stroke management and treatment is to preserve the quality of life. Once total paralysis total sets in, it tends to be irreversible most of the time. So we have to be very fast.”

Depending on which part of the brain is affected, the symptoms of stroke are sudden loss of speech, vision or movement on one side of the body or a drunken gait. In Priyangwada’s case, the girl was “born with a small defect and the bubble keeps changing as you grow and at some stage becomes very thin and bursts.” The commonest stage of a haemorrhage stroke is the third or fourth decade of life. His youngest patient to get the coil treatment has been a 10-year-old child.

The Sri Lankan girl went home after the treatment and returned to India only this February to complete her education. “Now I am absolutely alright but for some time I did suffer some kind of a partial memory loss. I forgot certain things; I remembered my parents, friends, etc, but couldn’t remember that my grandfather had died, or that my favourite cricketer — Jonty Rhodes — had retired. For some time I felt that if I could forget these things in the lives of my grandpa and my favourite cricketer, something was surely wrong with me. But now I feel absolutely fine.”