A Grandma Ate 1 Pound Chocolate In 6 Hours.
This Is What Happened To Her Brain.
LE is an 81 year old woman, presenting to the emergency room, unconscious.
Her son, Jonathan, tells the admitting nurse that she suffered one seizure with brief a
regain of consciousness before becoming completely unresponsive.
You see, LE is a grandma who was celebrating easter with her grandchildren.
This was not the religious ceremony, but one with an egg hunt, easter bunny and copious
amounts of chocolate.
This was an event held just for the kids, and LE was happy.
She was thrilled to be out of the retirement home, even if just for a few hours to be with
family for the festivities.
Because she was healthy for her age, and the kids would only eat the candy with nanna,
grandma ate much more chocolate than she wanted.
Immediately after finishing a total of 1 pound of chocolate,
LE complained of a burning stomach ache.
Unwilling to disappoint the kids, she kept quiet and smiled.
Over the next five hours, LE felt the need to use the restroom.
She had been constipated more often lately, but this time was much worse than before.
She struggled and strained with great difficulty to get a movement and was finally successful.
As she got up from the toilet and began to wash her hands, she experienced a sudden,
thunderclap headache.
In seconds, the pain rapidly escalated to become the worst headache of her life.
As she struggled down the stairs, she tells her son Jonathan that she’s starting to
feel nauseous.
The chocolate, they thought.
It must have been the cause of the indigestion and now nausea.
Nothing seemed too serious though, and they both believe some stomach remedies can alleviate
the issues.
Laying down now, LE felt worse than ever.
Her nausea, sitting atop her stomach.
Her headache, piercing through her skull.
Her neck, stiffening out of control.
She was reluctant to ruin her grandchildrens’ day so she kept quiet in the other room.
As her son and grandchildren watch TV for a few more hours, LE begins to vomit loudly
and suffers a seizure.
Jonathan rushes into the room to see his mother regain consciousness briefly before she falls,
completely unresponsive.
911 is called and the paramedics try to resuscitate her as she arrives to the emergency room where
we are now.
Given the patient’s history of present illness, there are several clues as to what’s happening.
Because she suffered a headache, seizure and loss of consciousness, clearly this is a problem
of her brain, but something’s wrong.
At physical examination, she regains consciousness but appears to be confused.
She is still nauseous.
She doesn’t remember easter with the kids.
She has no bruises visible on her skin which would indicate a possible bleeding disorder,
but their absence rules that out.
The events of LE’s problem will unfold on a timescale of days all tipped off, because
she ate 1 pound chocolate over 6 hours.
Her medical record indicates that she was very healthy for her age.
Previous checkup a few months prior noted that her medication list was minimal but she
did have a history of hypertension.
At presentation, her blood pressure is measured to be 186/90, meaning that while she may not
have been at risk for systemic bleeds, she was at risk of a brain bleed.
We can prove this.
First, because LE is 81 years old and hypertensive it means she was at risk of forming of intracranial
aneurysms, which are structural weaknesses along the the walls of blood vessels.
Intracranial meaning these arteries were in the brain and have been bulging along weakened
walls for some time and were ripe for rupture.
This risk was further increased because LE is a woman.
At 81, she is post menopausal, meaning she has been estrogen deficient for at least 2
decades compared to elderly men who still produce some estrogen in response to their
perpetual testosterone production that’s diminished with age.
Estrogen is a sex hormone which is conducive to the production of a protein known as collagen,
something that gives tissues like blood vessels elasticity.
When elasticity is limited due to diminished estrogen presence and because of advanced
age, hemodynamic stresses like high blood pressure produce turbulent flow, generating
vibrations that may coincide with the resonant frequency of the vessel wall, resulting in
structural fatigue, compromising vessel integrity and developing these saccular aneurysms.
A CT scan confirms that LE is suffering from subarachnoid hemorrhage.
A bursting of blood in the subarachnoid space, where the rupture occurred in the brain.
But how could this be?
If she doesn’t have a history of bleeding disorder and has been relatively healthy up
to this age, how could she have a massive hemorrhage in her brain now?
Well, there’s a few things to consider.
Because of her age, LE has limited gastric motility compared to someone 50 years younger.
Because chocolate is high in fat which isn’t quickly digested, it slows the movement of
gastric contents even more, meaning food stays in the gut for longer, increasing contact
time with the intestinal mucosa, drawing more water out of the stool than normal, hardening
it, causing constipation.
The struggle and strain LE had in order to eject the stool in her bout of constipation,
acutely increased her blood pressure and the resulting hemodynamic instability was enough
to rupture the aneurysm in her brain and cause blood to push into the subarachnoid space.
The aneurysm by itself wouldn’t rupture without additional strain placed upon it which
in this case, was precipitated by constipation onset by copious chocolate consumption.
The thunderclap headache, the nausea, the vomiting.
The pallor.
All of these onset because the rupture of the aneurysm sent blood into the subarachnoid
space of the brain at arterial pressure and began to push into her brain until the pressure
equalized at the rupture site and a formed a clot.
The bleed itself only occurred for a few seconds, but this problem isn’t finished.
Admission to the intensive care unit finds that LE has a 14% risk of aneurysmal rerupture
within the next 24 hours, with the risk increasing 1.5% for each day that passes and if she bleeds
again, LE has a 70% chance of mortality.
As the days continue, LE is given antifibrinolytic therapy.
Fibrin, referring to the final protein that forms blood clots, lytic meaning breakdown of
and anti meaning against.
A medicine that prevents clot breakdown.
Because a clot formed at the site of aneurysmal rupture, and that clot’s purpose was to
stop further bleeding, breaking down the clot, which happens naturally in the body would
increase the chance of rebleed, so inhibiting that breakdown should prevent rebleed, right?
It’s 4 days after admission now and LE is exhibiting cognitive deficits.
Her grandkids try to speak to her, but she sometimes drifts off and stares blankly, at
a loss for words.
Radiographic evidence shows that she is suffering from delayed cerebral ischemia.
A starving of blood in her cerebrum that’s delayed in onset.
If she bled in her brain, it means an abundance of blood flowed out into her subarachnoid
space, so how is it possible she has ischemia, a limited presence of blood?
Well, blood in the subarachnoid space has nowhere to go.
It’s not being pumped around the body anymore and that subarachnoid space is closed off
to the rest of the body, and is never supposed to have blood.
Since that space is closed, instead of the blood drying up, the red blood cells begin
to breakdown.
Hemoglobin, the iron containing protein that carries oxygen begins to deposit and decompose
into iron-containing methemoglobin, heme and hemin.
Hemin is known to release active iron that will begin to deplete anti-oxidant chemicals
naturally in the brain and produce iron-based free radicals that will cause lipid peroxidation
meaning they will begin to damage the membranes of brain cells, destroying them and because
brain cells do not regrow or regenerate, this cerebral remodeling could mean permanent brain
damage in LE’s case.
The brain in an effort to defend against this, responds by causing cerebral vasospasm, meaning
the blood vessels in the brain begin to constrict and as they begin to narrow, less blood flows
through her brain, meaning less oxygen is going to the tissue.
Explaining the term "delayed cerebral ischemia."
This vasospasm should make sense physiologically.
For example, when you get a cut on the skin, it becomes warm and swollen.
This influx of blood flow is due to vasodilation so that inflammatory white blood cells can
enter and kill bacteria and pathogens.
The skin has room to expand in the face of swelling, but the brain inside the skull does
not, and it reacts by preventing more blood from flowing in.
Even in the face of recovery, lasting cognitive deficits are a common long-term complication
observed in aneurysmal subarachnoid hemorrhage survivors.
Functional impairments in the ability to conduct daily activities are common in these survivors
and in LE’s case, a simple case of constipation because of 1 abnormal episode of abundant
chocolate consumption caused this intracerebral disaster.
The insignificance of daily living causing catastrophic injury in the elderly is a recurring
theme when it comes to causes of death in old people.
An insulin injection for a diabetic 90 year old grandpa can cause him to become hypoglycemic.
This is a time when his blood sugar is low and can be perpetuated at night time when
blood sugars are already naturally low.
Because he’s 90, it’s likely his prostate is enlarged because male bodies never really
stop producing testosterone which is a necessary condition for the prostate to keep growing.
This chronically pushes up against his bladder and at night he will have to get up to pee
but because he’s hypoglycemic, he’s dizzy and falls, shattering his hip.
Because surgical complications leading to death are relatively common in a 90 year old,
do we operate on grandpa if he has a chance of never waking up from anesthesia?
Or if his quality of life either way will be poor?
Some kids may laugh at “help I’ve fallen and I can’t get up,” and maybe even grandpa
himself would have laughed at that too when he was a kid, but falls and their resulting
fractures are a common cause of mortality in the elderly, and the statistics show that
for some of us, that is how it’s going to end.
In the case of post-surgical recovery, the elder patient may feel nausea from taking painkillers
They might lay on their back and in the case of vomiting, laying in that supine position
could cause them to aspirate and breathe in their vomit, causing pulmonary obstruction.
If they don’t choke on it first, they could contract pneumonia, forcing them on antibiotics
which could injure their kidneys, causing acute renal failure leading to cardiovascular
and neurologic dysfunction if they didn’t already have those already.
This will lead to a sooner death, all because they laid down in the wrong position at the
wrong time.
The elderly can commonly have a heart problem known as atrial fibrillation.
This is a time when one part of your heart will beat at over 300 beats per minute, not
actually contracting or ejecting blood.
It causes blood to pool, forming a clot which can lodge directly into your brain causing
a stroke, blocking oxygen flow to your brain.
A fibrinolytic drug, one that breaks formed clots, like this alteplase, is given.
If antifibrinolytics prevent aneurysmal rebleed, then the opposite fibrinolytic can cause a
bleed, which means treating an elderly patient’s ischemic stroke, puts them at risk for a hemorrhagic
stroke, just like in LE’s case as she ate 1 pound of chocolate in 6 hours, became constipated,
and in the struggle to pass a stool, she ruptured an intracranial aneurysm.
At this point, her aneurysm is stabilized and surgically clipped to prevent any possibility
of it rebleeding.
We give nimodipine, a blood pressure medication that selective for cerebral arteries, without
affecting the inotropy of the heart and it's given to LE to relax the arterial walls and
mitigate the vasospasm.
Because her delayed cerebral ischemia is symptomatic, we’ll induce therapeutic hypertension while
keeping her euvolemic, or at a normal body water status.
While keeping her blood pressure temporarily high, this will force blood into her brain
despite the narrowed arteries, and will only be done for a short time so as not to form
new aneurysms in her brain.
This flow of blood through an artery was the impetus for the study of rheology.
To study the flow of blood meant to study the flow of fluid through a cylinder, which
describes the flow of water through pipes, and electricity through wires, one of which
is the principle of how you are able to watch this video, and you can use that principle
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With continued monitoring in the ICU, a diligent medical team, and a loving family at her side,
LE was able to make a recovery.
Thank you so much for watching.
Take care of yourself.
And Be well.