Dr. Babak Jahromi, MD, a neurosurgeon at Northwestern Medicine, talks about a life-threatening brain bleed that was caused by chemotherapy and how he and his team managed to save his patient’s life.
Interview conducted by Ivanhoe Broadcast News in June 2022.
What is a brain bleed and what causes it?
JAHROMI: Bleeding in the brain can be caused by a number of factors. They can relate to an inability of the blood to properly clot. If you are on blood thinners or if there is a problem with the blood clotting factors, you can have a spontaneous bleeding in the brain. Another cause can be things such as a brain aneurysm or a brain vascular malformation. Lastly, as we age, the brain becomes more fragile and a bit more prone to have spontaneous bleeding.
With your patient Ali, was the cause of her brain bleed from cancer treatment from?
JAHROMI: Correct. Ali is a very uncharacteristic patient who presents with a brain bleed. Ali does not have a brain aneurysm. She’s very young. She doesn’t have the kind of bleeding in the brain we would see in a more fragile brain of an older patient. Ali had bleeding in the brain because she had a problem with the clotting factors and in this case, specifically, the platelets. These are cells that help the blood clot. But, even more unusually, this was because of her cancer and the chemotherapy drugs given to try to cure her cancer.
Do you see that very often?
JAHROMI: Not very often. The type of cancer Ali had is relatively uncommon. And getting bleeding from that cancer to the point where it’s life-threatening is even more uncommon.
Is it always life-threatening when your brain bleeds?
JAHROMI: Not always. There’s a lot of brain bleeds that we can watch and do not require treatment. Ali’s was very different for two key factors. One is, it was a very large bleed. And secondary, the other factor in whether one can survive and tolerate a bleeding in the brain is how much room you already have in the skull. The skull is a fixed space. It doesn’t have room for more stuff, so either the bleed has to be small or, as we age, the brain slowly atrophies and opens up a bit more room. Ali had none of those going for her. She’s very young, has a full brain and has a big bleed and that caused huge pressure on her brain.
Where in the brain was this bleed?
JAHROMI: Ali’s bleed was on the right side of her brain, the right hemisphere. And in this case, it was causing significant pressure, encompassing almost half of the right hemisphere.
What’s the danger of that? What could happen?
JAHROMI: The skull doesn’t have room for more than the brain itself. As more material is pushed into it – in this case, as bleeding occurs into it – the pressure rises minute by minute. And that pressure starts destroying the remaining on her brain. So, you can only tolerate pressure on the brain for so long. An increasing pressure drives you to deeper and deeper levels of coma and eventually death.
How did you find out this was going on with Ali?
JAHROMI: Ali initially presented with bruising, and based on blood tests and lab tests, she was diagnosed with this type of cancer. For that reason, she was admitted for chemotherapy and then developed a very bad headache. That, for us, is a very tell-tale warning sign. Someone who’s on chemotherapy, which we know will affect the platelet counts and potentially cause bleeding in the brain, complaining about a bad headache raises the big fear of now bleeding in the brain. So, an emergency CAT scan showed the bleeding.
Were you shocked at the amount of blood?
JAHROMI: Not necessarily shocked, but very concerned.
What did you have to do?
JAHROMI: Initially, Ali had enough consciousness to stay aware of her surroundings and respond. She was immediately admitted to the intensive care unit and appropriate medication given to her. We can help buy some time by having somebody sit up and give them medications to reduce the pressure in their brain. But in her case, that did not prove to be enough.
What was the procedure that had to happen then?
JAHROMI: Generally, if somebody has bleeding in the brain, the first measure is to stabilize them. So, they’re admitted to the intensive care unit. All these measures are taken. Usually, that buys enough time to then prepare to decide if you need surgery. Can we give you other medications? Can we give you platelets? In Ali’s case, because the bleeding was so large, things spiraled out very quickly. So, she was admitted to intensive care unit, and within hours, this hemorrhage in her brain expanded and now she was sliding deeper into a coma to a point where she was near death.
What happened then?
JAHROMI: At that point, we have emergency medication. If somebody is progressing that quickly, you don’t really have enough time. In a young brain, the medications can only buy so much time until you can either remove the bleeding or remove a large portion of the skull to make room for the brain to swell outwards. In Ali’s case, she had so much pressure that her right side of the brain was now squishing into the left side and down towards normal parts of the brain, causing what we call a herniation. That’s a life and death situation. In this case, we can give emergency medications to buy minutes to maximum, let’s say half an hour or so, to get somebody into the operating room for an emergency operation. We can tell the effects of it by looking at someone’s eyes. If you are herniating, one of the telltale signs is the pressure on the brain affects the nerve going to first one eye and then the other. So, your pupils dilate, and in Ali’s case, we had dilation of one pupil and slowly the other. She was put on life support, the emergency medication given to her to buy some time and rushed to the operating room. Again, usually, we have some time with this medication so that by the time we’re the O.R., we can get the large portion of the bone off and make some room. So instead of the brain pushing inwards, it has room to swell outwards. In Ali’s case, that medication bought us maybe 15, 20 minutes max. And in the O.R., again, that pupil started dilating, which means you now have very little time. You have tried all your mechanisms and the only thing remaining is to get that bone off as fast as you can to make room for the brain to swell outwards as opposed to inwards.
Is it all about making room and then the brain can heal itself?
JAHROMI: Correct.
How long does it take to recover from that?
JAHROMI: Recovery from a brain injury is very long. That isn’t measured in terms of days and weeks. It’s measured in terms of months and years. But the key is to give someone the chance to survive. There’s no recovery if you’re not going to survive. If we could give her that one chance, she’s young, she has an amazing team behind her and she has a shot at it. But the issue is, can one in those minutes and hours, snatch her back from what was assuredly death?
Have you seen Ali since the surgery?
JAHROMI: I have. It’s a remarkable coincidence in that we did not know at the time, but her roommate ended up being engaged to one of our residents who happened to be on call that night, who first admitted Ali to the intensive care unit. So, it’s a very small world. So, we’ve actually had a chance to share her pictures, see her recovery. I’ve seen her back in clinic. From someone who was at death’s doorstep to now being able to swim laps in a pool despite her disability is just a miracle. I don’t think she would have survived in other circumstances and perhaps not other institutions. Having someone of this age present with this type of cancer takes a tremendous amount of work on behalf of the cancer team to get them to a cure. And not all cancers are curable. And then in the middle of treatment for what could potentially be curable, to have what could have been a catastrophic life ending hemorrhage and then still be able to recover from that and then go back to chemotherapy and obtain a cure and go on with life. I think it’s not just a testament to fortune, to having the right people at the right time, it’s also that Ali is a unique individual. She has immense strength, immense courage, immense determination, and an incredible family who has been supportive of her every step of the way. That combination of factors does not happen often, and I don’t see often in my job.
How do you protect her from this not happening again?
JAHROMI: In my field, we’re used to seeing patients with brain hemorrhages. They’re not often in young patients. They tend to be in older patients and they’re not often in patients with cancer. So, one of the biggest questions that we have to ask before going for what’s essentially a Hail Mary pass of somebody who has herniated, has almost died in the ICU once, and now they’re on their way to the O.R. and they’re dying again, you have to question what you’re doing. Will it help and what is the end result? And the few minutes as we were rushing, I had a very frank discussion with Ali’s oncologist. I asked her, “Do you think on your end, is there a future after this?” Because if this is not a curable cancer or if we save her life, but then we’re not going to treat the cancer, then in a sense, we’re putting her through a lot of grief and suffering for a very uncertain outcome. And we have to also give credit to our oncologists, our cancer docs, because they were there through thick and thin. And they basically told me, “No, this is curable. You need to give it a shot. If she lives, we will do everything on our end. Do your part. We’ll do our part.” And we need to hear that. It’s 2 in the morning. You have to make snap decisions. And they were fantastic. After several weeks, they were able to get Ali back on full chemotherapy. They’ve stuck with her for the entire year or two that it takes for the treatment to complete itself. Ali had to come back for a repeat operation to put the bone back. That gives an interruption in the chemotherapy. So, I have to give credit to our oncology team who, in the background, has helped every step figure out how to prevent another hemorrhage, how to interrupt the chemotherapy, the less give a chance and then put the bone back, then go back on chemotherapy. So, it’s a very delicate interplay between multiple specialties, all united to give her a shot at another life.
Is she more at risk of this happening again?
JAHROMI: She certainly was during the chemotherapy. Of course, that takes a year or two. Now that she’s off chemotherapy, that risk, while always a little bit there because she has that existing damage, is vastly better because her blood counts are back to normal and her cancer, by all effects, is cured.
END OF INTERVIEW
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