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The Case of the Stop-and-Go Blood Flow

Brain and magnifier--for hemorrhage and thrombosis detectivesThe patient came to the hospital weak and lethargic, with a terrible headache. The patient also could not move one eye.

This patient would turn out to have two serious problems: two different kinds of stroke. But, in a unique turn of events, the second one would seem to “fix” the first.

Figuring out the trouble–and deciding what to do about it–was the task of attending physicians Dr. E. Sander Connolly and Dr. Philip Meyers. Chief Resident Dr. Jason Ellis and third-year resident Dr. Nikita Alexiades assisted, and they are the lead authors on a new paper about this patient’s case. (The doctors have kept this patient’s age and gender anonymous.)

The patient’s first problem was a stroke due to hemorrhage, or bleeding in the brain. A small tear in an artery had let blood begin to flow in between the layers of the artery’s walls. This led to a bulging, weakened area in the artery’s outer wall. This ballooning area is called an aneurysm. Eventually the outer layer could not withstand the pressure, and the aneurysm burst, causing the brain hemorrhage.

Blood hemorrhaged into the brain, raising the pressure inside the patient’s skull. Such an increase in pressure is bad news for the brain.

And then there was the second “problem”: a blood clot. A blood clot, or thrombosis, in a brain blood vessel is usually not great news either. Normally, a blood clot in a brain blood vessel leads to another dire issue: ischemic stroke. Without blood flow, the brain soon begins to suffer from lack of oxygen and glucose.

But in this case, due to the exact location of the clot and the anatomy of the patient’s blood vessels, the brain did not experience a lack of oxygen. The rest of the brain received enough blood through other vessels.

And the clot completely stopped up the bleeding artery, putting an end to the hemorrhage. The second stroke had cancelled out the first.

The hemorrhage detectives themselves: Drs. Ellis, Alexiades, Connolly and Meyers
Top: Residents Dr. Jason Ellis and Dr. Nikita Alexiades. Bottom: Attending physicians Dr. E. Sander Connolly and Dr. Philip Meyers

It is pretty unusual for a blood clot to stop this specific type of hemorrhage without causing any harm. In fact, according to Dr. Ellis, this is the first documented case of that happening…ever.

When our doctors relieved the extra pressure caused by the hemorrhage, the patient improved. Then the doctors had a choice to make: perform brain surgery to definitively seal off the damaged vessel? Or closely monitor the artery, avoiding the risks of brain surgery if at all possible? This patient’s type of aneurysm was especially rare, so very little data existed on which to base a decision.

Dr. Ellis explains what the doctors decided, and why:

“In unique cases such as this, where the presentation is a mix of vessel thrombosis [aka blood clot] and hemorrhage, a nuanced approach must be used … delayed surgical intervention is a reasonable approach, as it may facilitate detailed [study] of the [problematic] vessel, allowing for preservation of critical brainstem [blood vessels].”

And that’s what happened. Doctors monitored the patient closely. After several months, they found evidence that blood was starting to flow through the problematic vessel again, but that the vessel hadn’t completely healed. To prevent any further bleeding, they decided to perform surgery after all.

But first they conducted detailed studies of the blood vessels in the patient’s brain. That way, they could be completely sure to operate so that other vessels would be able to continue to provide blood to the rest of the brain.

Dr. Ellis, Dr. Alexiades, Dr. Connolly and Dr. Meyers could find no other reports of a case like this. They published this report so that their experience may one day be able to help another patient.

The paper was originally published in BMJ* Case Reports, and has been re-published in the Journal of Neurointerventional Surgery.

Learn more about Dr. Ellis and Dr. Alexiades on their pages here and here.

Learn more about Dr. Philip Meyers on his bio page here.

Learn more about Dr. E. Sander Connolly on his bio page here.

*British Medical Journal

Image credits: Brain: ClkerFreeVectorImages/[Pixabay]

Magnifying glass: OpenClipartVectors/[Pixabay]

patient journey

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