January 14, 2006
Sharon Still Unconscious; Recovery Prognosis Sinks: U.S. Doctors Say That Speed of Progress Key to Rebound From Stroke
By Ronald Kotulak, Chicago Tribune
Jan. 14--Israeli doctors expressed growing concern Friday that Prime Minister Ariel Sharon still has not shown any signs of consciousness more than a week after suffering a major bleeding stroke on the right side of his brain.
For someone incapacitated by a severe stroke, time is the enemy, according to experts. The longer it takes for significant signs of recovery to appear, they said, the poorer the prognosis.
The most critical period is the first month after a massive stroke, when doctors can assess how much brain damage has occurred through a patient's responses--opening the eyes, becoming conscious, following commands, and breathing and moving on his own.
"If he doesn't have any voluntary movement three or four weeks from the onset, that's a really poor prognosis," said Dr. Richard L. Harvey, medical director of the stroke rehabilitation center at the Rehabilitation Institute of Chicago. "At that point you figure that he's probably not going to become a very functional person."
Sharon has been unconscious and on a ventilator since suffering a hemorrhagic stroke 10 days ago, despite recent efforts to bring him out of his medically induced coma. He was listed in stable but serious condition, and his life continues to be in danger.
The brain has amazing recuperative powers, and people with milder strokes often return to normal or near normal function. But recovery depends on such factors as the age of the patient, the degree of brain damage caused by the stroke and how quickly rehabilitation is started.
All of that appears to be creating uphill battles for Sharon, 77, who had to undergo three operations to relieve excessive bleeding and dangerous pressure in his brain.
Complicating Sharon's prognosis is the coma he was put in to reduce damage to his brain caused by swelling. Doctors at the Jerusalem hospital where Sharon is being treated are attempting to discontinue the anesthesia infusions that induced the coma in order to determine if he is capable of responding.
Sharon's doctors earlier had reported some preliminary positive responses, including moving an arm when pinched, an increase in his heart rate when his son spoke to him, and brain scans showing that the blood that had pooled in his brain had been absorbed.
Much of the pressure on the brain is relieved when the blood is gone, giving neurons a chance to recover, said Dr. Mark Alberts, director of the stroke program at Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital. Alberts and other medical experts interviewed said they were reluctant to assess Sharon's condition but shared their experiences with patients who suffered similar major strokes.
"Looking at the big picture, it appears that he survived the acute insult, which is good, and it appears that he's showing some early recovery, which is good," Alberts said. "In terms of is he going to recover from this and be neurologically normal, I think that's highly unlikely. Is he going to recover and have some impairment, I think that's a likely scenario."
The ability of patients to participate in rehabilitation is key to their recovery. Scientists have learned that mental and physical exercises can cause the brain to rewire itself so the patient relearns functions lost as the result of a stroke.
Physical rehabilitation may initially involve passive activity in which a therapist moves affected limbs in reaching or walking motions. Once feeling begins to return, a patient can be trained to use mechanical devices that gradually improve movement. Other therapists can help patients learn how to talk and read again.
There are two types of strokes that affect people and Sharon had both. The first was a mild stroke Dec. 18 caused by a blood clot that lodged in an artery in the brain, cutting off blood flow and causing minor damage.
A day before Sharon was scheduled to undergo surgery to repair a hole in his heart that doctors thought might be responsible for the clot, Sharon suffered a severe bleeding stroke.
In this type, arteries rupture and pour blood into the brain, causing swelling that can destroy neurons. About 25 percent of the stroke patients at the Rehabilitation Institute have this kind of hemorrhagic stroke, Harvey said. Patients with small strokes do very well, he said, but the chance of recovery decreases with the severity of the stroke.
Outside doctors have criticized the prime minister's physicians for putting him on a blood thinner after his first stroke to reduce the risk of further clots. The drug carries a risk of increasing bleeding in the brain, especially considering Sharon also was diagnosed with cerebral amyloid angiopathy, a condition that weakens small blood vessels and makes them more prone to rupture.
On Friday his doctors also were considering a tracheotomy, in which a hole is made in the neck for a breathing tube. The procedure is done to wean a patient off a ventilator, which can cause serious problems with prolonged use.
The longer Sharon remains in his condition, the graver the outlook, said Dr. Demetrius Lopes, a Rush University Medical Center neurosurgeon.
"The main predictor of how things are going to go is based on how fast we see signs that he is following commands and being able to become as independent as possible," he said. "The longer it takes for that to happen it means you're farther away and there's less of a chance to have a full recovery.
"After nine days he has had very slow progress and that indicates more permanent injury to a level where his quality of life is affected," Lopes said. "And then decisions will have to be made."
Tribune foreign correspondent Joel Greenberg contributed to this report from Israel
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