A runner’s life-threatening brain bleed is repaired just in time thanks to a new minimally invasive procedure. Patient Mikal Scott talks about his alarming symptoms and fortunate meeting with neurosurgeon Dr. Jared Knopman, who performed the pioneering technique that’s now providing patients with a far better treatment option for this condition.
Dr. Stieg: I'd like to welcome my two guests this morning, Mikal Scott, a marketing consultant who is an avid and extremely dedicated runner as well as Dr. Jared Knopman, who is an Associate Professor of Neurological Surgery and specializes in minimally invasive access to the brain. Thank you so much for being here. And I wanted to start by talking about Mikal's medical issue that resulted in his presentation to the emergency room. And it's a subject that is becoming more common in America with the aging population is something called subacute or chronic subdural hematomas. Dr. Knopman, can you kind of explain what this means?
Dr. Knopman: Sure. So a subdural hematoma is when blood builds up between the dura, which is the covering over the brain and the brain itself. As we all age, our brain begins to shrink away from that covering and that space becomes bigger. So we become more prone to having an accident and then bleeding into that space. As you alluded to, Dr. Stieg, with our aging population, subdural hematoma is predicted to be the most common neurosurgical condition by 2030.
Dr. Stieg: You can't see Mikal, but he's not old. And that's what makes this a little bit unusual is that it can affect people of younger ages, correct?
Dr. Knopman: It can. What essentially happens is there are veins that run between our brain and the covering over the brain. And after someone gets hit in the head or a minor trauma, those veins can tear and bleeding can occur. And what happens is the blood clot builds up and it forms a membrane around itself. Although the bleeding can stop that blood clot may not go away on its own and it can cause pressure on the brain. It can cause neurologic deficits, and it can happen even in young people such as Mikal.
Dr. Stieg: So one would think that an avid runner like Michael and a businessman wouldn't be very susceptible to having this kind of problem. Mikal, can you tell us a little bit about your story? How did you notice this and what happened?
Mikal Scott: Sure. All of a sudden I started getting headaches. I literally didn't know what was going on in my life and I would find myself lying down in the middle of the day having to stop meetings because I couldn't continue because it just hurts so badly.
Dr. Stieg: Yeah, personally, I've had patients that have had just terrible sneezing episodes — elderly, and they started having this problem. Or another common scenario that I've seen is with these amusement parks going down the water slides, and where you get ripped around and, and the important thing is not to think about blunt trauma, you know, a blow to the head, but your head can be shaken, i.e. playing football and frisbee and things like that. You said that you had headaches — I'd like to get into also the emotional about this. You know, you said you had, you couldn't complete your business meetings. You knew you had to sit and lay down. Did that have an emotional impact on you?
Mikal Scott: Ah, very much so. But, when you're trying to come up with creative solutions for problems, you need to be thinking all the way through. If you can't think from beginning, middle, to end, your idea is worthless. And having to walk out of a meeting, and in the middle of discussing a problem, it has an effect on you.
Dr. Stieg: But what I found astounding when I was reading about your story is that you still managed to grunt through a 5K run with all this pain?
Mikal Scott: Well, I joined this club here in New York called Central Park Track Club and it turned out we're a bunch of all Type A personalities who run really, really fast. And every time you race you have to race. And then I started vomiting from the headaches. I induced vomiting, I felt better and I went out and I ran. Yes, I didn't run a great time, but it was for charity for police officers who have died in the line of duty. So I sorta felt like I really needed to pull my end up. I've got, I was going, "I only have headaches. These guys died." Yeah, so, and I went through and I did it.
Dr. Stieg: So it was a little bit interesting here as I understand also that you did seek medical care and you were told to do some minor things and Dr. Knopman, how common is that in this scenario that he has this what turns out to be a significant problem and it's a little bit overlooked?
Dr. Knopman: Well, sometimes subdural hematomas will go away on their own and we will give medical therapy and observation and close follow-up to see if that happens. By the time Mikal came to see me, his subdural hematoma had not gone away on its own. He was continuing to have symptoms from it and in fact it was slowly enlarging. And at that point, more definitive treatments need to be undertaken.
Dr. Stieg: When you're talking about medical management, what should the listeners hear from a doctor?
Dr. Knopman: So medication that we can take orally by mouth, something called decadron. It's a very low dose steroid, it's an anti inflammatory. And we feel that what helps keep these subdural hematomas alive is an inflammatory process. And if you take an anti inflammatory like steroids, it can sometimes interrupt that inflammatory process and help the subdural hematoma resorb go away on its own with time.
Dr. Stieg: Mikal had passed that point. What are the next options that are available to him?
Dr. Knopman: Traditionally, in neurosurgery at that point, open surgery to drain the blood clot has been our mainstay form of treatment either by putting burr holes through the skull or by making a window in the skull to take out the blood clot. For the last 50 years, that's been our standard of care for how we treat subdural hematomas.
Dr. Stieg: You've popularized a new minimally invasive technique for managing this blood clot over the surface of the brain without having to make holes and involving surgery. But before we get to that, I'd like to hear from Mikal how he got to finding you.
Mikal Scott: Well, my primary care physician got me to look at get CAT scans and she sent me immediately to the emergency room and I was checked in and I was in for four days, lots of tests, an awful lot of tests on me. And after four days they asked me to be discharged and they really weren't sure what to do with me and they said, please go see your primary care physician again in three days and I can tell you that I didn't make it to the three days. And within a day the headaches had gotten massively worse and I was lucky because I live close to downtown Presbyterian and I went to the emergency room and it just so happened my cardiologist was there that morning. They did whatever they had to do, which I do not know because I had no idea what was going on.
Dr. Stieg: You got to our emergency room and was it love at first sight with Dr. Knopman, or what happened?
Mikal Scott: Well, I can tell you something about this guy. The first time I met him I went, "Yeah, this is the place I am supposed to be." It's embedded in my brain. The way he walked in, the way he sat down, the way he addressed me, quite confident, in being able to say, "Mr. Scott, you're not going to die."
Dr. Stieg: This is something I like to touch on. It's the doctor-patient interaction. I understand the sense of confidence, but there is, is there something else that, that a doctor can communicate to you as a patient?
Mikal Scott: Yes. Giving me the information. He explained to me exactly what was going on. I love science and my father, he was with NASA. I grew up around the space program in Bermuda and when he spoke to me I got it and it really made me feel like I was part of the process. You know, he was telling me, these are your options, this is what we can do, this is what has been done historically and we have this new technique and I immediately went, "I'll take that. I'll take that."
Dr. Stieg: We talked a little bit earlier about the standard technique, which is more invasive. Dr. Knopman, can you go into detail about the minimally invasive technique that you're popularizing?
Dr. Knopman: So by the time a chronic or a subacute subdural hematoma hasn't gone away and it persists and it stays on top of the brain and it's causing pressure, it has formed a membrane around itself that keeps it alive and it has recruited blood vessels to this membrane to feed it. Most patients that we see with chronic subdural hematomas have blood of what's called mixed acuity, meaning mixed ages. There's old blood, there's more new blood. And even though someone may have had a trauma, only one time that they can recall, a subdural hematoma can continue to bleed into itself without subsequent trauma necessary. So there's a recruitment factor that goes into these subdural hematomas that keep them alive. And the new treatment that we've pioneered here addresses that root cause, that recruitment of blood vessels, and interrupting those blood vessels to then allow the brain to do what it would normally do on its own, which is resorb the blood and get rid of it with time.
Dr. Stieg: So how do you go about doing that?
Dr. Knopman: So we do this minimally invasively through what's called a endovascular embolization, where we can navigate through a needle stick in either the artery in the leg or on the wrist, and we can navigate catheters up into the blood vessels that feed the covering of the brain that feed the dura. We're not going into the brain itself. We're going to the blood vessels that feed the covering over the brain and then we shut them down. These blood vessels, believe it or not, are extraneous and they're pathologic, meaning that they're only feeding the subdural hematoma. They're not providing any function or importance to brain structures or anything like that. So they're sacrificible and by interrupting that blood supply, we prevent that vicious cycle from happening, that recruitment of blood vessels, that re-bleeding that keeps a subdural hematoma alive, and in the subdural hematoma is able to resorb on its own.
Dr. Stieg: I get why you would pick something like that. You know, you avoid a haircut, you avoid an incision, a hole in your skull. What was it like experiencing it when you went through the process?
Mikal Scott: I have to say that, the fact that there was no surgery, that was great. I remember Dr. Knopman asking, do I want to be put out, and I said, "No, I want to know and I'm going to listen to what was going on." And I was allowed to look up and I could watch what he was doing for a bit. And then once he got to where he had to go, he had put, I remember him putting my head down. It was all very, very organized. So you felt like, wow, this is nice and smooth and very relaxing for me.
Dr. Stieg: Like NASA with dad. *laughs*
Dr. Knopman: Well, Mikal alludes to a very important point, which is that this procedure can be done in someone who's awake. So if we offered brain surgery or had to drain this hematoma, it would typically be a procedure where you would be either highly sedated or under general anesthesia. You'd be in bed for multiple days afterwards. You have to remember, unlike Michael, who is young and fit, this pathology strikes people who generally are more elderly and fragile. Avoiding general anesthesia in an elderly patient, avoiding bedrest in an elderly patient. These are half the reasons patients have poor outcomes. So to be able to offer a technique that takes these other associated risk factors off the table is very powerful in this patient demographic.
Dr. Stieg: You felt no pain, it was quick and easy?
Mikal Scott: I remember him doing it. I remember feeling it, kind of feeling it tickling along my brain. You remember I, I said something, "Wow, it feels really weird inside there, just enough." Um, but after that, I remember you talking about, we have to close it and then after that I remember being in back in the room recovery room. Yeah. In the recovery room and family was there. People were there and I was like, "Hey, what's going on?"
Dr. Stieg: You went through the procedure and did you leave the hospital the next day?
Mikal Scott: I don't remember what time of day. I know we left very quickly. I was surprised at how quickly—
Dr. Stieg: What'd you do when you went home?
Mikal Scott: Ate.
Dr. Stieg: How quickly did you get back to work?
Mikal Scott: Uh, probably I started within a couple of days.
Dr. Stieg: So how is that different from having a craniotomy? What would have been his course?
Dr. Knopman: if you had a craniotomy, you would have been in the hospital for at least two to three days. You would have been laying on your back flat. You would have been immobile, you would have been at risk for other things that occur when you're immobile, like pneumonias, clots in your legs. This gets you in and out. There's no recovery as, as you know, Mikal, because it's just a needle stick in the leg that you're recovering from. Not an incision, not pain, not immobilization.
Dr. Stieg: And I should clarify that a craniotomy is making a hole in the skull and that's why the recovery takes so long. How quickly did you get back to running?
Mikal Scott: Well, I have to put a little, you—
Dr. Stieg: You cheated. *laughs*
Mikal Scott: Well, I kind of cheated, and then on that first followup he says, "Please stop doing that." I had this little program for myself where I was doing these little exercises at home and he goes, "I'll let you know when." He told me, "I'll let you know when." And I believe it was 60 days to the day that I went out for my first run.
Dr. Stieg: When you went back to work, like you said, in a couple of days, did you notice that you were able to have those meetings and you are creative and you were back to your old self again?
Mikal Scott: I knew from the time I woke up I was fine.
Dr. Stieg: And if you get a CT scan or an MRI scan immediately after you do this therapy, is there any big change in the imaging?
Dr. Knopman: So what's interesting is that because this process works by interrupting that vicious cycle, it does take time for your brain and your body to resorb that blood. But people like yourself will oftentimes feel better even before the blood goes away. Headaches will oftentimes get better even though the blood doesn't go away. This procedure has taught us about the cause of subdural hematoma in a way that we never understood in the past. We thought this was a disease of just veins, that tour and that was it. Now that we see the involvement of inflammation, the involvement of arteries, the involvement of these nerve fibers on the dura, we have a whole new appreciation for what a subdural is and what ultimately leads to its cause.
Dr. Stieg: You got back to your running. Tell me about that.
Mikal Scott: The following spring I got invited to run with our team at the Penn relays and I'd never done that before, but it was the following winter indoors at the Millrose Games here in New York City that I was on the 4x400 team and we were on the podium, we came in third place, and it was truly, I was like, yes, I'm finally okay. Life is normal. Yeah. Yeah, it was, it's a good thing.
Dr. Stieg: Dr. Knopman, tell me a little bit about the physician's role in managing his expectations and managing his family's emotional wellbeing.
Dr. Knopman: Well, I would say I was very lucky to have had Michael as a patient. I didn't know until today that you're the son of, of someone who worked for NASA because you yourself were a pioneer in this. You were one of the first five people in the world to get this treatment. What I think the benefit of this procedure is and something that you clearly understood from the inception, it doesn't take off the table potential for surgery, potential for drainage if it doesn't work. But it offers an upfront alternative to surgery if it does. So it's basically win-win: the procedure's low risk, the upside is very high. You're able to avoid surgery, but if it doesn't work, we're right back to where we've been always for the treatment of this disease, which is surgery. So, having a patient like yourself understand that, open to trying something innovative, open to exploring this other option. It's very important. And, and patients like yourself who have undergone this procedure have now helped, in my opinion, make this and continue to make this what I think is going to be the growing standard of care for how we treat subdural hematomas.
Dr. Stieg: I really want to thank you both — it's a heartfelt thank you for sharing with us both the complexity of the brain, but also the fragility of the brain. I mean, here you are, this dynamic businessman running marathons and running these sprints and you almost potentially lost your life. The brain is an extremely fragile organism. In your case, it was being compressed by this blood clot on the surface, but there's also biochemical and physiological changes that were altered by the treatment provided by Dr. Knopman. Those are all important things that doctors like Dr. Knopman take into consideration when they're treating patients like Mikal. I want to thank you both really for sharing.