Delayed Gratification

An aneurysm is a bulge or ballooning of a blood vessel that is prone to rupture, due to reduced resistance to pressure exerted by the column of blood within. Such aneurysms can be located anywhere in the body. When ruptured, the blood extravasates into the surrounding tissue. When this happens in the brain for instance, the pressure within cranial cavity sharply rises owing to its fixed capacity, like a pressure cooker. And just like a pressure cooker lets out steam through an opening when the pressure goes above a certain threshold, the brain is pushed through major openings in the skull. This process is known as herniation and could have profound and most times irreversible effects leading to brain death.

Suffice to say, a ruptured aneurysm is a medical emergency and SSSIHMS neurosurgery department prioritises ruptured aneurysms irrespective of the time of arrival. One such example is Mrs Nagamma, a 61 year old lady who was brought in an altered sensorium to the casualty at 3 am on 31/12/23. The patient had bled on 26/12/23 and then again on 28/12/23. She had initially been treated at Tumkur and CT head had shown subarachnoid haemorrhage with a thick clot in the anterior inter-hemispheric fissure. CT angio revealed an anterior communicating artery aneurysm and a right sided posterior communicating artery aneurysm. The Glasgow coma score on arrival was E2V4M6. She was taken up for emergency surgery in the wee hours of 31/12/23, a Sunday. A right pterional craniotomy and clipping of the aneurysm was performed. Surgery was uneventful.

Post operatively the patient was GCS 15/15. She had lower limb weakness on both sides. On the 6th post operative day the patient’s sensorium dipped and the angiogram revealed vasospasm in the left ACA vessel. Vasospasm is constriction of the blood vessel and happens due to irritation to the vessels caused by degraded blood products in the subarachnoid space usually between the 3rd to 21st days after SAH. It is a serious complication as the arteries supplying different areas of the brain are ‘END ARTERIES’. This means there is little to no collateral blood supply and can lead to death of neurons in that territory. If reversed in the early stages, where it has not caused neuronal death, the neurons can be salvaged. Chemical or balloon angioplasty of the vessel in spasm can be done with conventional angiography. She underwent chemical angioplasty on 4 consecutive days. Her course was further complicated by hyponatremia, LRTI and UTI which were managed appropriately. CT thorax was suggestive of post COVID-19 sequelae that delayed weaning off of oxygen support.

During the course of the hospital stay, Nagamma was shuttled between the ICU and ward on 3 occasions due to her volatile condition. The doctors and nurses at SSSIHMS believe in not signing off prematurely on any patient no matter how grim it might appear on the surface due to many previous examples of delayed recovery. This requires astute judgement that comes with experience as there needs to be a delicate balance between worthwhile effort and resource preservation. A stormy course immediately following surgery is often followed by prolonged convalescence, especially at home where exposure to familiar environment and people motivates the patient’s subconscious to a more alert state. This was evident in the last few days of Nagamma’s stay when we would observe her eyes light up trying to reply to grandchildren over the phone, a response that we were only able to elicit with intense coaxing.

Care-giver stress needs to be acknowledged in the management of patients needing prolonged care. Staying away from home, awaiting an update each day, new place, dwindling resources takes a lot out of the bystanders. Bystanders losing a job or losing business is not unheard of. Many are known to sell their possessions to pay for the expenses.These often under appreciated sacrifices take a toll on the bystander’s mental and physical health. Nagamma’s son needs a special mention for his positive spirit standing by her during this entire ordeal. When asked what kept him going, he said it was the love and gratitude for his mother primarily. He recollected how he would immerse himself in hospital activities voluntarily lending a hand to ‘sevadals’ wherever he could, none of it by anyone’s compulsion. A man with a spiritual background, his faith in a higher power kept his mind from diverting towards negative thoughts or emotions.

Nagamma was discharged on 6/2/24 after 37 days in the hospital. Her sensorium remained M6 on deep coaxing but her lower limbs weakness persisted. She needed oxygen support and was referred to a local hospital for the same. We hoped that being amidst her loved ones would be a strong motivator for recovery. We saw Nagamma in April 2024 for her 3rd month follow up. She was still in a wheel chair, and was able to walk a few steps with support at home. She was not able to speak much during the time.

December 31st, 2024 an old lady walked into the Neurosurgical OPD and sat in the chair opposite me with her son who’s face was vaguely familiar. On opening the chart, I was astonished to see that it was the same patient we had operated on, precisely a year ago. I found out that she did not remember the hospital, the doctors or nearly anything about her stay here. Apparently, she was wheel chair bound and spoke very little the first 6 months and suddenly made a quick recovery after. The patient and son thanked the team profusely and expressed their gratitude for all that the hospital has done for them. For the few months lost, the patient had gained many years of meaningful life. It was indeed gratifying to hear that she spends her time with her grandchildren and is very happy.

Efforts don’t always pay off in Neurosurgery. Majority of the moribund bed-bound patients eventually succumb to complications from prolonged inactivity such as pulmonary embolism and MI within a year. Nagamma’s story emphasises the need for good social support and motivation in the recovery of these patients. Outcomes like this further bolster our resolve to never give up on patients prematurely.