Archive for the ‘atrial fibrillation’ Category

Acquired Brain Injuries: Causes and Impact

Tuesday, May 17th, 2011

On the heels of Jason Penn’s blog regarding calling “911″ for signs of a possible stroke, I decided to introduce a variety of acquired brain injuries for further discussion in future blogs since damage to the brain results in some of the most catastrophic injuries possibly sustained by the human body with significant “collateral damage” for all of the friends and family involved in the individual’s life.

What is an “acquired brain injury”?

Wikipedia defines acquired brain injury as damage to the brain occurring after birth but not including neurodegenerative diseases, such as Parkinson’s or Alzheimer’s, that occur later in life.  These injuries can further be divided into traumatic and non-traumatic acquired brain injuries.

Traumatic brain injuries are a result of some kind of trauma to the cranium/brain, but the actual causes can vary significantly. Trauma, in general, is the leading cause of death in the young-adult age group. An obvious example of a significant head trauma is the gunshot wound to the head sustained by Arizona Representative Gabrielle Giffords earlier this year. Other examples are assaults with blows to the head, falls with blows to the head, car or bicycle accidents with head injuries, sports-related head injuries/concussion, childhood playground head injuries, and even damage sustained during brain surgery. The degree of damage and permanent sequellae obviously varies as well, ranging from fully recoverable within a few days to catastrophic permanent deficits and even death. Interestingly, the amount of external damage (or lack thereof) does not necessarily reflect the damage inside the cranial vault.

Non-traumatic acquired brain injuries, on the other hand, have a wide range of etiologies not related to head trauma that have just as wide of a range of catastrophic effects and recovery times. One of these causes is a stroke, as described by Jason Penn; however, strokes can be either ischemic (blockage of blood flow to the brain by, for example, a blood clot) or hemorrhagic (when a blood vessel in the brain ruptures), and each is treated very differently!  Other possible causes are infections, brain tumors, failure of other body organs (liver, kidney), loss of oxygen delivery to the brain (heart attack, blood clot in lungs), other chemical or drug ingestions with toxic effects, aneurysm rupture, and build-up of carbon dioxide in the blood stream from other lung pathology, including smoking!

A Virtual Tour of the Brain

Described as the most complex organ in the human body, the brain has been the subject of numerous educational videos, which attempt to give the layman a better understanding of the parts and functions of the human brain. YouTube has numerous “brain anatomy” videos for you to peruse. Here’s one from the University of Bristol that does a good job of providing the basics of this incredible organ.

httpv://www.youtube.com/watch?v=9UukcdU258A

Effects of Brain Damage

The brain is the body’s 3-pound computer that controls every conscious and unconscious function of the body. Different areas of the brain control different cognitive, behavioral and emotional functions as well as the everyday metabolic functions of the body. Damage to specific areas of the brain result in specific functional losses, which is why someone with a “stroke” might experience numbness and weakness of one side of the body or no weakness but loss of balance or loss of vision. Larger injuries result in more brain tissue damage and more functional deficits. The object of “the game” is to rapidly diagnose the problem and rapidly treat the problem in order to minimize the amount of brain damage, and thus, minimize the functional deficits. Many acquired brain injuries progressively worsen due to different “normal” pathophysiologic mechanisms. It is imperative to intervene sooner whenever possible.

A Personal Story

My uncle had a stroke 1 month ago while working in the yard.  ”911″ was called immediately, and he was transported to the closest hospital.  He apparently had an undiagnosed abnormal heart rhythm (atrial fibrillation) that caused a large blood clot to form in the heart. This clot ultimately got pumped out into the carotid artery and lodged itself at the beginning of the middle cerebral artery on right side of his brain.  He was initially unconscious, but he later “came to”, only to deteriorate into unconsciousness again as the brain swelled from the blocked artery and infarcted brain tissue. He was transferred to another hospital that was capable of performing brain surgery, and he had back-to-back brain surgeries on 4/10 and 4/11 to try to minimize the damage. They actually had to remove a large part of his skull to allow for the brain swelling to occur without the brain’s tissue being compressed against the skull so as to prevent herniation of the brain.

He was in a coma for several days, but he is slowly making some recovery. In the meantime, he needed a tracheostomy and feeding tube in his stomach, both of which he still has. His entire left side remains completely paralyzed. It is difficult for him to stay awake, although he does seem to know who is around at any given time. My aunt, God bless her, has spent the last month at the hospital, 8 hours or more every day, and she is just exhausted. It is unclear when he will be going home or even if he will be going home. We are hoping and praying for the best recovery possible, but the future remains uncertain.

Collateral Damage

In addition to the person affected by acquired brain injury being functionally limited, whether temporarily or permanently, there is often collateral damage to himself/herself as well as to friends and family members. Emotional issues often arise, whether through mood disorders like depression and anxiety, or with actual personality changes. Those affected can become more belligerent or difficult, angry, withdrawn, and a host of other characteristics, making it very difficult on the person caring for the affected individual. The physical demands alone can overwhelm the care-provider (like bathing, toileting, feeding, transporting to appointments, etc.) and lead to care-provider stress and mood disorders.  Financially, these injuries are often devastating. Marriages end; relationships among family members suffer; sometimes, physical abuse and neglect can even occur when frustrations become overwhelming.

There are support groups available many of which can be accessed through local hospitals, associations or your health department.

Locally, you may want to visit the Brain Injury Association of Maryland and the Brain Injury Association of Washington, D.C.

Stay posted for more details on some of these causes of acquired brain injury specifically. In the meantime, do you have a story to tell?

 

Image from neuroskills.com

A New Blood Thinning Drug is Approved – Pradaxa – better than Coumadin?

Friday, October 22nd, 2010

This week’s press release by the US division of the German based Boehringer Ingelheim pharmaceutical company is certainly a breakthrough for patients. The company announced the FDA approval of their drug Pradaxa (dabigatran etexilate). This is the first new oral anticoagulation drug approved in the US in more than 50 years.The drug was approved for stroke and systemic embolism prevention in people who have atrial fibrillation not caused by a failing/defective heart valve.

The press release touts impressive results. National studies have shown when Pradaxa 150mg was taken twice daily, there was a 35% reduction in stroke and embolism when compared with the traditional drug known to most as Coumadin (Warfarin). In addition, at the same dosing level both types of stroke (embolic/clot and hemorrhagic/bleeding) were greatly reduced when compared to Coumadin. More good news for patients taking the drug…

  • Very few drug interactions,
  • No more dietary restrictions, and
  • No more routine blood testing and dosing changes as required when taking Coumadin.

WHAT IS ATRIAL FIBRILLATION AND WHY DO YOU NEED TO TAKE BLOOD THINNING DRUGS?

Atrial fibrillation is a heart rhythm disorder caused by a malfunctioning electrical conduction system within the heart – see video.  It is usually identified by an irregular rapid heart rate that begins in the upper heart.The smaller 2 upper heart chambers, known as the atria, begin to contract quickly and in an irregular fashion. As electrical signals leave the atria and enter the 2 lower heart chambers known as the ventricles, they too begin to contract quickly and in an irregular fashion.  This irregular and rapid heart rate is unable to pump the blood through the heart and out to the body in a strong, efficient manner. Thus blood can pool in the heart and the lower extremities allowing clots to form. These clots dislodge and travel to the heart, lungs, and brain leading to a stroke. Therefore it is important to prevent the clots from forming by correcting the abnormal heart rhythm,  and by lowering the blood’s ability to form dangerous clots.

The press release noted an estimated 2.3 million Americans have atrial fibrillation and the number is expected to increase to 5.6 million by 2050. A large US-based managed care organization used their data to show 95% of all persons with atrial fibrillation have no heart valve problems. Atrial fibrillation increased the risk of stroke 5 times, and is an underlying condition in 15% of all US strokes. Atrial fibrillation related strokes are twice as likely to be fatal or severely disabling when compared to strokes from other causes.

MedicineNet.com today reported recent studies by the New England Journal of Medicine and the American Heart Association found Pradaxa was also more effective in preventing clots in patients experiencing acute coronary syndrome. Sweden reports the drug can be safely used in conjunction with Plavix and Aspirin drug therapies.

WHAT ARE THE DOWNSIDES?

With the good news, comes the drug’s downside. The company is forthcoming in reporting Pradaxa when administered in 150mg doses results in a higher rate of gastrointestinal bleeding related complications when compared to Coumadin. This dose was reported to also cause an increase in adverse GI reactions such as dyspepsia, abdominal and gastric pain, GERD, esophagitis, gastritis, and ulcer. Importantly, in patients older than 75 years of age, the risk of bleeding complications may be greater than Coumadin. Also noteworthy is the finding that the risk of myocardial infarction was greater in studies with patients taking the 150mg dose than those taking Coumadin.

The company warns patients taking other blood thinners, non-steroidal anti-inflammatory medicines, St. John’s Wort, and any drug that can cause abnormal bleeding reactions need to be avoided. Over the counter medications are included in this warning. The company’s public package leaflet notes the drug will interact with Amiodarone and Verapamil and Pradaxa dosing will need to be reduced. The drug may also affect the liver but not more then Coumadin. It is contraindicated in patients who are in kidney failure, liver failure, and pregnancy. Some report a Quinidine interaction.

The FDA has approved dosing in capsule forms of 75mg and 150mg twice a day. Those persons taking larger doses of 150mg need to be fully informed of the above possible complications before switching from Coumadin to an easier life with Pradaxa.

EASIER TO LIVE WITH, BUT WHAT WILL IT COST?

It will take 3 to 6 months before distribution begins and pricing is not known. As with any new drug introduced in the US, speculation is the cost will be just short of prohibitive. Canada Pharmacies online sell Pradaxa 60 capsules both 75mg and 150mg doses at approximately $350.00 each. Generic Coumadin 100 pills at variable doses sell for approximately $34.00 to $50.00. The high drug price for US patients may offset the life style improvements for many who pay out of pocket for drugs. It is not known if prescription drug plans will approve partial or full payment for the drug.

It is generally reported that Coumadin is not a popular drug. Consumers and physicians alike resound with the same low opinion of the drug.  It is a difficult drug for physicians to manage, and it has a great impact on quality of life for patients. If Pradaxa continues to show its improved lifestyle value with no hidden serious side effects, patients will be the winners. Hopefully over time competitors will surface and prices will be driven into an affordable range for the growing US atrial fibrillation patient population.

UPDATE: Interesting piece by Dr. Wes on Pradaxa just posted today. Thought you may want to read. The comments have been coming in fast and furious on this new “wonder drug.”  Here’s the post by Dr. Wes – Pradaxa, Your Days are Numbered

Related Post:

Follow-Up Blog: Important Questions and Answers on Pradaxa