Case 1 : Ruptured intracranial aneurysm

 

Stacy was a 27-year-old young, energetic woman who had found the man of her dreams.  John was a firefighter who was looking forward to settling down and starting a family.  Stacy was just the woman for him and they had been dating for six months.  On May 14, 1999, they had been out on a date and returned from dinner.  They went to John's apartment and sat on the couch staring in each other's eyes.  All they saw was the love for each other and the night turned into a wonderful evening.  John had contemplated proposing marriage to Stacy but had been hesitating for fear of rejection.  Stacy had been wondering what was holding John back but figured on giving John the time he needed to decide to propose.

 

John stood up from the couch and went to the kitchen to pour some drinks.  The thought crossed his mind about losing Stacy but he still had not yet built up the confidence to propose.  When he returned to the living room, he saw Stacy slumped over, her eyes rolled back, her body shaking like she had been gripped by a seizure.

 

John dropped the glasses of wine.  His heart skipped a beat as he ran over to Stacy and tried to awaken her.  So many horrific thoughts flashed in front of his eyes.  He was in a state of panic as Stacy would not awaken.  Her body was stiff and she failed to respond.  She was still breathing, her heart was still beating.  John ran to the phone and called 911.

 

The paramedics arrived and rushed Stacy to the local hospital emergency room.  She was placed on a respirator and still remained unconscious.  The emergency room physician obtained a CT scan of the brain.  John was anxiously pacing in the waiting room when the emergency room physician came out and informed John that Stacy had suffered catastrophic bleeding in the brain and needed to be transferred to the medical center under the care of a neurosurgeon.

 

What would happen to Stacy, is she ever going to awaken, can we undo what just happened?  These are the questions racing through John's mind.  His future looked dark, black.  "God, I hope the neurosurgeon can help Stacy, oh please."

 

I arrived in the ICU shortly after Stacy was transferred.  I had to pass by the private waiting room where I noticed a nervous man pacing around.  I knew that he would have been the boyfriend of the patient I was about to evaluate.  I also knew the situation was grave based on the story I heard from the emergency room physician.  After evaluating Stacy, I met with John.  Stacy had no family in Houston and John was her only well wisher.

 

I explained to John that Stacy had a subarachnoid hemorrhage that was likely secondary to a ruptured intracranial aneurysm.  I had recommended an intracranial angiogram followed by surgery to clip the ruptured aneurysm.  She had suffered significant neurologic loss of function and it was not clear that she would be able to make a meaningful recovery.  Clipping the aneurysm was the only way to prevent re-ruptured and death.  She also had a buildup of fluid pressure in the brain and would need a drain placed to allow excess cerebrospinal fluid to drain out.

 

John sobbed inexorably.  He kept shaking his head mumbling repeatedly "Oh why God did I not marry her."

 

As it turned out, the intracranial angiogram did demonstrate a ruptured aneurysm.  I took her to the operating room and performed a craniotomy, an opening in the skull, in what was a risky yet necessary operation.  I placed a ventricular drain relieving the pressure that had built up.  With the aid of an operating microscope, I exposed the blood vessels to the brain and identified the ruptured aneurysm.  A clip was placed along the base of the aneurysm, thereby obliterating it.  Stacy was now safe from the risk of re-rupture of the aneurysm.

Examination of Stacy demonstrated improvement of her neurologic condition.  She was still quite lethargic but was not comatose and could now move her extremities.  John was ecstatic and exclaimed, "Dr. Bindal, thank you so much!"

 

I explained to John that unfortunately her condition remained critical.  With a ruptured aneurysm, patients can suffer from vasospasm which is a reaction to subarachnoid hemorrhage.  The blood vessels to the brain can constrict causing a stroke resulting in significant neurologic deficit or even death.  Realizing that she was at risk for stroke, I took measures to reduce that likelihood.  Her blood pressure was increased, the volume of blood in her body was increased with fluids, and the viscosity of her blood was maintained at the most optimal level.

 

Despite all measures to maintain blood flow to her brain, Stacy became symptomatic from vasospasm and began to show signs of stroke.  The left side of her body became weak from paralysis.  John became terrified.  His lips trembled hearing the news.  He shared the story of his love for Stacy with me.  John begged repeatedly, "Please Dr. Bindal, please do everything you can to save my Stacy.  I should have married her.  You are my witness- dear God, please save my Stacy.  If Stacy can survive this ordeal, I will marry her, no matter what."

 

I felt sorry for John.  After carefully thinking about options for Stacy, I offered John one last hope for Stacy.  I spoke to the radiologist and worked out a treatment protocol for injection of a drug directly into the brain vessels that dilates the vessels and could counter the effects of vasospasm.  The effects would be temporary, and not without some risk but would offer the only hope for meaningful recovery.  John concurred.

 

The treatment worked miraculously.  Stacy's left-sided weakness improved immediately and quite significantly, back to normal.  I could see the sigh of relief John's eyes.  I was elated to see John's happiness. 

 

The next morning, however, the left-sided weakness returned.  Once again, John begged of me to do something for his Stacy.  John prayed for Stacy and asked me to join hands with him and the pastor.  During the prayer, I felt compelled to do my best for Stacy.  I decided to convince the radiologist to repeat the procedure.  The treatment was repeated, and Stacy left-sided weakness resolved once again.

 

Unfortunately, the following day, Stacy again developed left-sided weakness.  I advised John that it was dangerous to keep repeating the procedure and that at some time we would need to give up and let the stroke be complete.  John repeated his vow to marry Stacy.  After much discussion, we proceeded to treat Stacy for a third day and agreed this would be the last.  Stacy responded to the treatment with resolution of her left-sided weakness, and I found John praying for Stacy that night.

 

The next day, Stacy did not develop any left-sided weakness.  After two weeks in the ICU, Stacy's condition stabilized.  She survived her bout of vasospasm without any significant neurologic stroke.  She was transferred to the floor where she showed continued dramatic improvement of her condition.  She was then sent for rehabilitation.

 

Three months later, a lovely young woman entered my office and held out her hand and spoke, "Thank you, Dr. Bindal, for saving my life."

I had difficulty recognizing this lady until I saw John walking behind her and then I knew this was Stacy.  Her neurologic condition had returned to normal and even as a neurosurgeon, it was difficult to perceive that she had suffered any bleeding in her brain.  "Guess what Dr. Bindal, we are getting married!"  exclaimed John.  John and Stacy enjoyed a wonderfully blissful marriage since then.