“Stopping Stroke—Blocking Brain Bleeds”
Neil Martin, MD
Neil Martin, MD, Chairman, Department of Neurosurgery at UCLA, talks about a new
procedure for brain hemorrhages.
What is a brain hemorrhage?
Dr. Martin: A brain hemorrhage is one type of stroke. Brain hemorrhages can occur
from a ruptured brain aneurysm, but really the most common cause of a hemorrhage in
the brain is hypertension. Hypertension, high blood pressure causes weakening of the
small blood vessels in the brain and when they rupture they cause intracerebral
hemorrhage.
What happens to the patient?
Dr. Martin: When that occurs, typically a patient experiences a headache, then they
have a neurological deficit that may be impairment in speech or paralysis of an arm and
leg. In severe hemorrhages, they may lapse in to a coma.
So you as a surgeon you have to go in and fix that problem, what traditionally
would you have to do?
Dr. Martin: For these patients when they hit the emergency department, they look like a
stroke patient. We have to get a brain scan immediately and that shows the hemorrhage,
a CT scan will show the hemorrhage. As a surgeon, I have to decide do they have a
large hemorrhage that’s life threatening that has to be removed in order to prevent
pressure from building up and impairing brain function and causing progressive
deterioration, or do they have a small hemorrhage that can be managed conservatively,
medically and allow them to recover spontaneously.
Now for these patients do they suffer the same type of symptoms like stroke
people, do they become paralyzed on one side? Does all that extra blood on the
brain basically have that affect?
Dr. Martin: In the case of an intracerebral hemorrhage, bleeding in the brain, the
symptoms are stroke like. But they often involve a little more slowly than they do with
traditional strokes. In an ischemic stroke where a small clot blocks a key brain blood
vessel, the same kind of process happens in a heart with a heart attack, there’s a
neurologic deficit that occurs almost immediately. They’re paralyzed right away, they
can’t speak, and they may be unable to walk. In an intracerebral hemorrhage, often the
bleeding progresses over minutes, fifteen minutes, a half an hour, hours sometimes. And
that increase in bleeding causes progressive slowly developing neurological deficit. They
may have a headache initially then they may develop impaired speech, then paralysis of
an arm and a leg. That evolution is something that we see more often in an intracerebral
hemorrhage.
With this type of hemorrhage are the affects reversible?
Dr. Martin: So the key thing that happens with an intracerebral hemorrhage that can be
corrected surgically is that the pressure builds up and that can impair the function of the
brain. Once the blood leaks out of blood vessels, it releases toxins in to the brain tissue.
Probably relate it to the iron in hemoglobin, which causes progressive swelling in the
brain. There are two things going on, there’s the immediate pressure effect and then
there’s this toxic effect that builds up over hours and even days and that really is what
we can impact. Now, we can’t do anything about the disruption or tearing of nerve fibers
or damage to brain cells that occurs mechanically at the time that the hemorrhage
develops. We can certainly relieve the pressure by removing the blood clot and we can
remove all of that blood that is gradually acting as a toxin in the brain.
Until now it’s been a pretty invasive surgery to get rid of this hemorrhage, the
blood?
Dr. Martin: Right. In the past we did a craniotomy, that involves a large incision on the
scalp, opening a window in the bone, taking a bone plate out, making an incision through
the brain and then visibly usually with the aide of the operating microscope removing,
sucking out the blood that is in the brain. So, you’re doing good by getting the clot out
and relieving the pressure, but you’re potentially doing harm by retracting on the brain,
incising the brain. Many of the studies that have been carried out in neurosurgery have
suggested that the invasiveness of a craniotomy, large open surgery may negate the
benefits of getting the clot out.
Seventy five percent is the mortality rate?
Dr. Martin: Intracerebral hemorrhage really is the last unsolved problem in acute stroke.
We just don’t have a proven therapy for it and it’s the most devastating kind of stroke,
the stroke with the highest mortality rate. We’re looking for more effective, less invasive
ways of evacuating, removing the blood clot, relieving the pressure, getting the toxins
out, and that really is what this new procedure is about.
When that hemorrhage happens is it more of the hemorrhage that causes the
death or the invasive part of the surgery after such a traumatic event that causes
it?
Dr. Martin: We have suspected that invasive open craniotomy may cause so much
harm that it negates the benefit of getting the blood clot out. In some cases, it may
impose an additional stress on the patient that can cause further complications. The
death rate from intracerebral hemorrhage is tremendously high, and this is something we
want to affect with a procedure like this. The key is not just to have the patients survive,
but survive in a severely disabled or vegetative state. The key is to have the survivors
recover and have a quality of life.
Is this new surgery helping to do that?
Dr. Martin: Our view is that this operation offers the ability to remove the blood clot
without imposing additional insult or damage to the brain.
What is this new procedure called?
Dr. Martin: The new procedure that we’ve developed is a stereotactic endoscopic
minimally invasive approach to removing brain hemorrhage. Basically, it involves using a
GPS like system to steer an endoscope that could be used as a suction port to remove
the blood clot without making a large incision in the brain. We’re putting an eight
millimeter sheath, or catheter, or tube directed in to the blood clot, and we’re steering it
to the center of the blood clot using a computerized image guided system that works off
the CT scan or the MRI scan that’s been obtained as the patient is being evaluated.
Where do you go through so there’s no opening of the skull?
Dr. Martin: The opening we make is what we call a burr hole but it’s a small opening in
the bone that’s about the size of a nickel. It allows the introduction of this catheter or
sheath into the hematoma and the incision is about an inch long. We put the incision in a
location that’s going to give us the most benign, the least harmful trajectory and pathway
in to the blood clot and yet still give us good access to the blood clot.
How long would the traditional surgery take compared to this one, and what about
recovery that one compared to this one?
Dr. Martin: An open craniotomy typically takes two and a half to four hours to open the
bone, go in evacuate the clot and then close everything up. This procedure takes under
an hour and it involves a very short incision and within fifteen minutes of starting, the
procedure the blood has already been evacuated.
Is there a time frame that you have to get the blood out for the best results?
Dr. Martin: This procedure usually is not done as an emergency. In the first few hours
there’s ongoing bleeding and the situation is rather unstable. We try to stabilize the
patient by lowering their blood pressure and allowing the bleeding to stop. This minimally
invasive procedure makes it difficult to actually get to a bleeding blood vessel and stop it.
We wait until the bleeding stops and the situation stabilizes. It’s that first twenty four to
thirty six hours that are critical. Beyond that much of the damage is done the pressure
has taken its affect the toxic byproducts of blood have been released in to the brain so
we try to get in that first thirty six hours to get the blood out before these delayed effects
have a chance to take hold.
What’s the difference in recovery?
Dr. Martin: There’s not a dramatic difference in shortening the stay in the hospital
because the stay in the intensive care unit is designed to treat the damage done from
the initial effects of the hemorrhage. What we do find however is that the patients are in
the intensive care unit for a shorter period of time. They generally move from the acute
care hospital into a rehabilitation program earlier and that has significant benefits in
getting them back to the road to recovery. We’re working with Johns Hopkins and I’m
working with another doctor here. The study of a new surgical procedure is very
complex. It requires collecting a lot of data, evaluating a substantial number of patients
and intensive care is a critical part of the recovery. I’m working on this project with an
investigative team from Johns Hopkins led by Dan Hanley and I’m working with the
intensive care director here at UCLA Paul Vespa. That team is critical to bring a new
procedure in to the standard clinical realm.
This information is intended for additional research purposes only. It is not to be used as
a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional
interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or
accuracy of physician statements. Procedures or medicines apply to different people and
medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Elaine Schmidt
Senior Media Relations Officer
UCLA Health Sciences Media Relations
(310) 794.2272
eschmidt@mednet.ucla.edu
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