Stroke of Bad Luck in the Senate

As if any of you residents or med students need this, StopPagingMe.com would like to remind you that your health is precious and this case of a bright, active, generally healthy Senator form South Dakota, helps to remind us of that.
Senator Tim Johnson (D) of South Dakota was conducting a conference call yesterday with reporters when he began stuttering and according to the Associated Press report, became somewhat incoherent. He recovered enough to ask if there were any additional questions but “appeared ill” to his staffers - ill enough to rush him to George Washington University Hospital. (When they heard a VIP politician was coming, as I’m sure they are pre-warned of political emergencies such as these, how many of them thought Cheney was on the way again?)

Shortly after the conference call, spokesperson Julianne Fisher said he was undergoing evaluation for stroke-like symptoms.
Upon arrival to the ED, it’s likely that he was sent directly for CT or angio (or both) to rule out intracranial bleed and/or stroke. In the meantime, their stroke team was activated as there has been a push in the medical world to more aggressively address acute cerebrovascular events. Many hospitals, particularly large academic tertiary centers have established stroke teams with fancy names like GWU’s “Brain Attack Team”.
StopPagingMe.com’s physicians were obviously not in the radiology bullpen when the image came across but what they saw impressed them enough to take him for “emergent surgery,” according to numerous reports. [We wonder whether it was the resident who first viewed the shots and how quickly he called his attending? Pretty damn quickly we would guess.]
Sometimes when media reports “surgery” they do not differentiate between interventional procedures and open surgical intervention, so we were skeptical that perhaps they found an aneurysm that could be coiled or a thrombus that could be lysed.
However, the AP stated that doctors had to “drain blood from the brain” which implies a surgical evacuation to relieve pressure. Thus, the images most likely showed fresh blood with a midline shift and urgent need to relieve the pressure and stop further bleeding and permanent damage to cerebral architecture.
Following the surgery Senator Johnson is most likely recovering in the neuro ICU with very close attention paid to intracranial pressures and further bleeding episodes. This will be a very telling few days for the politician and his family as his mental status and recovery prognosis will come into focus. But until he can be removed from sedation and off the tube (ventilator) very little can be assessed besides brain stem reflexes and electroencephalgographic (EEG) findings (which will be blunted by sedation).
On the educational tip, an anteriovenous malformation (AVM) is a cluster of congenital arteriovenous communications without intervening capillaries. The arteries and veins are tortuous and dilated and they are more commonly supratentorial, occuring in the parietal lobe, middle cerebral, posterior cerebral, and anterior cerebral territories in decreasing frequencies. Only about 10% of them are infratentorial, i.e. cerebellar and below.
Here are the cold hard numbers with regard to AVMs: In an unruptured AVM, the incidence of first bleed and the annual re-bleed is about 4%. The annual mortality rate due to an AVM is 1%, with the mortality at the first bleed being 10%. In patients presenting with a bleed, the possibility of recurrence was 25% in the next four years, and that of a third bleed is 25%within one year of the second episode.
Studies suggest that only 34% of patients with AVM remained symptom free; 26% become symptomatic and partially disabled; 11% are severely disabled. Hemorrhage is the most common presentation with an incidence of about 70%. Unlike an aneurysm, AVMs bleed, more frequently during sleep and are unrelated to stress, trauma, or hypertension.

Digital angiography is still the imaging mode of choice. A detailed study of the arterial feeders, the nidus and venous drainage is mandatory.

Surgery remains the gold standard. Other modalities are considered only if a safe surgical excision without any long-lasting morbidity is not feasible. If possible, surgery is usually delayed for a few weeks (as the rebleed risk is much less unlike in aneurysms) unless the hematoma requires emergency evacuation.

Worthy links:

www.thamburaj.com/cerebral_AVMs.htm - Nice summary

http://neurosurgery.mgh.harvard.edu/neurovascular/ - Nice images

http://www.brain-surgery.com/bsicavm.html - Sweet video of the procedure

2006-12-15