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 to learn even more about fluid mechanics from
Brilliant.org, who helped sponsor this video. Brilliant offers courses and problem solving
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into the school of your dreams, or a working professional who wants to stay competitive,
you need logic and reasoning to stay sharp and be in a position to reach your goals. Brilliant takes complex subjects like physics
and gives stories and situations in easily digested nuggets, that aren’t like 1 pound
of chocolate in 6 hours, and gives clear rationale in each part, all to tie the concepts together
in a logical conclusion. Signing up at Brilliant is free from the link
below in the description and the first 200 people to subscribe from brilliant.org/chubbyemu
will get 20% off. 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.
Can I get a TL;DW summary please?
Seriously. We need a revision of the Wadsworth Constant. I am proposing that the last X percent of a video will be an advertisement from the narrator for some bullshit site to make you smart.