Au revoir, Sir Perimesencephalic SAH

It was 9.30 pm 14th November 2024. We were about to retire to bed. Like a bolt from the blue, a typical thunderclap headache occurred. Strictly confined to my forehead on either side of the midline. Over the next 30 minutes, the intensity increased fivefold. I had never in my 74 years experienced any such pain. As I had given a lecture “Recognising the dangerous headache” at least twenty times to different groups and had also contributed a chapter on this topic, I was more than familiar with dangerous headaches!!

In fact, a question I had submitted to the National Board of Examinations for their question bank was “Management of complications, following subarachnoid hemorrhage in a 75-year-old”. I had argued that the response would bring out the very best in a student – knowledge not just about diagnosis and treatment but the importance of QoL and Quality of Death.

My body was following exactly what I had written, but my mind would not accept the fact. My profession was to diagnose, treat, and teach, not be teaching material for future generations of neurosurgeons!! The incessant increasing headache was now followed by persistent vomiting and neck pain. A good MBBS student and a nursing student should have only one diagnosis Subarachnoid hemorrhage (bleeding below the arachnoid membrane, one of the layers in the meninges, which covers the brain).

Recollecting all this in a few minutes, and accepting the inevitable I called the Director of a quarternary care Neurosciences Centre. As we were staying in a gated community in the suburbs it was 90 minutes before I reached the ER. Expecting to become drowsy and progressively decline I informed the ER staff that should things worsen I did not want any heroic treatment.

To the annoyance of the CT technicians, I insisted on seeing the images myself (the on-call radiologist would see the pictures at his home). Sitting before the console (headache was responding to the IV medication), as I had done from 1979 till a few years ago (the third CT scan in the country was at the Institute of Neurology MMC, where I was trained), I studied the images on the screen in great detail, as I had done for thousands of patients over several decades.

Surprisingly I was oblivious of the fact that it was my damaged brain that I was now studying. I recalled, that as a guestimate, over 45 years, I would have personally managed about 600 patients with sequelae of SAH and at least a hundred acute cases.

In the earlier decades, the mortality was high (10 to 15%). Many of the survivors had severe residual neurological disability. In the last decade due to phenomenal improvements mortality and morbidity have considerably reduced but SAH in the elderly could still be a critical condition.

A very senior neurosurgeon particularly familiar with SAH, as a patient, is a nightmare for the treating team!! Wheeled back into the ICU, I could not help listing the recommended SoP to be followed! A few hours later, I was wheeled into the angiography suite. All 5-6 nursing assistants, nurses, technicians, and supervisors were of the opposite gender.

Preparation of the groin for a femoral puncture is no doubt mandatory. In my anxious state of mind, I felt the whole team was being super enthusiastic. The nurse described in great detail what would be done.

My “private parts” were now in the public domain. Do not know what would have been my reaction half a century ago. At this point, felt like quoting publications providing evidence that shaving before a craniotomy actually increased infection due to microscopic bleeding and parting hair over a long scalp incision would suffice. Anyhow wisdom prevailed. I let the team do what they wanted to do!! The various PPPs in which I had played a role (Telehealth projects with the government) flashed through my mind. Decided to consider this, another PPP project.

Strapped and restrained to the angio table I tried my best to look at the half a dozen high-resolution monitors which even showed 3D reconstructed color renderings of my entire intracranial vasculature. There was pin-drop silence during the entire procedure. The Head of the Interventional Neuroradiology section very politely but firmly informed me that he would revert asap with the report, after digitally manipulating the pictures and studying the hundreds of images generated. The suspense would continue!

Back in the ICU with a massive bandage over my right groin, I was warned of the risk of rebleeding at the puncture site, if I moved my right lower limb by even 1 cm!! for the next 10 hours. With iv Mannitol and Normal Saline, my frequency of micturition had increased. I asked for a urinal to empty my bladder. To my horror, a 20-something young female insisted that she place the urinal properly. In all fairness, her only motive was no doubt to ensure that the bed sheets would not get soiled!! I valued my privacy but her stern, uncompromising countenance made it clear that I was not part of the decision-making committee. Meekly I complied. This had to be repeated several times over the next 48 hours with different “young things”. Even my spouse’s offer to do the needful was not accepted!! “Professionalism and Technical competence”, I thought to myself.

A few hours later I was shifted to the MRI scan for a recently approved special protocol study on “Vascular pathology” of intracranial vasculature.

Almost 3000 images with 1mm slice thickness were analyzed to detect segmental pathology. Unlike conventional MRI scans, this study takes 50 minutes and sound levels are much higher. On 3 occasions I was about to press the abort button but good sense prevailed seconds before. It is a globally accepted finding that when a specialist clinician is a patient many investigations are equivocal. Findings were documented on the Angio and MRI. However, whether the association was causal or casual was left unanswered. On Day 7 the angiogram was repeated with no new findings.

I was therefore diagnosed to have “ Angio -ve SAH – Perimesencephalic type”. PMSAH was identified as a distinct entity only in 1985. This hemorrhage is restricted to the cisterns in front of and around the brain stem. A literature search (done in between angiograms!) revealed that PMSAHs are venous in origin. Variations in the venous drainage system of the midbrain, particularly involving a more primitive drainage system of the basal vein of Rosenthal have been postulated.

This subdivision of SAH (5%) as per follow-up, has a good prognosis with negligible complication rates or risk of re-bleeding. Prevalence is 1 per 200,000 population. Presentation in the eighth decade is probably 1 in 300,000. Considering the fact that even today there are only 9.75 neurosurgeons per million global population, the number of neurosurgeons in the eighth decade with PMSAH was probably worth reporting!!

Who knows my story of a full dress rehearsal, a dry run as it were of what normally is a one-way journey, of how a possible visit to the Pearly Gates was thwarted by the Almighty, a case report later of a 10-year survival would be in the offing. Improbable Yes! Impossible No!

Thank you, God, my family, and my large extended family for now making me see things from a patient’s perspective. If only I had been practicing, I would have been a far better doctor AI and DH notwithstanding.

This–could-have-been-critical–episode reiterated, from personal hands-on experience, what I have been stressing for decades, that all the technology on the planet, all the forthcoming humanoids and chatbots can never, ever, replace a sympathizing, empathizing young nurses or duty doctors who hold your hand and reassures you that everything is fine (when you know it may not be !!).

As a DH evangelist, I am all for the use of appropriate technology but am concerned, that TLC administering health care providers, may become an endangered species