Vascular

09-May-2023

A physiotherapist friend of mine recently said 'vascular patients are just ...different'. Lets call him Luke, since that's his name.

Luke currently works with amputees in a reputed healthcare setting in Wales¹, but as many UK¹ physio's do, he previously spent time on the neuro- wards. Patients come to neuro- wards for a variety of reasons, head injury, stroke, dementia being but a few. As you can imagine, there are various grades of severity of all of these, and patients are also stratified into groups according to their condition. At the larger hospitals, these groups of condition x severity form a ward. Some wards are peacefully / disturbingly quiet, others are more regular.

Luke has a gift. Luke knows how to read people to a level I have rarely seen in another human being, and this is one of the characteristics that make him exceptional at his job. So, I trust him when he says vascular patients are unusual, and I have gathered its an opinion held by a variety of healthcare professionals. I am completely fascinated as to why.

What do we mean by unusual? Some personal anecdotes. My grandparent had vascular dementia, manifesting in the usual way. Something I noticed at the beginning, even as the self-absorbed teenager I was at the time, was that his diplomacy skills vanished. This disappearance was notable even above and beyond the mysteriously socially accepted crotchety-old-man archetype. Another note, this time from a clinical, superior colleague of mine: A patient's wife described going to a dinner party with her husband. The husband was recovering from a moderate-severe traumatic brain injury, affecting, as many do, the corpus callosum area of the brain, a feature I will discuss in a moment. At this dinner party, the host kindly served some drinks and food of apparently average quality, for the patient remarked, loudly, 'this food isn't very nice, is it?'. Polite dinner conversation indeed!

About the corpus callosum (CC) - this area of the brain acts as a white matter tract superhighway linking left and right hemispheres of the brain. There is very few sites that this can be done due to the brain's generally divided structure, left brain, right brain. The CC structure can easily be damaged or stretched in traumatic brain injury, but also in the cerebral hypoperfusion (read: not enough blood flow to the brain) associated with neurovascular disease i.e. vascular dementia, stroke.

If the two halves of the brain are damaged, and in addition cannot communicate to each other in the usual way via the CC due to damage of the original network structure, the very thoughts, emotions and even movements that the patient can make are changed. In a degenerative condition, these are typically changed forever. The patient becomes a different person, with different personality and perception of social norms and their surroundings due to their new brain pathology.

How is vascular disturbance related to brain trauma? An outcome of vascular disturbance is cell death. If cells die by other means e.g. severance by direct trauma, the outcome, or effect on the patient, can be the same. In addition, vascular disturbance is inherent to traumatic brain injury. The swelling of the brain inside the skull as a confining box results in a squashing ischemia of the blood vessels, as well as bleeding at a micro (bruise) or macro (haemhorrhage) level where these blood vessels have been broken. To talk of traumatic brain injury is to talk of vascular damage.

Luckily, vascular damage can heal. And with a good blood supply, among other favourable conditions, so too can the brain. This is due to a phenomenon called neuroplasticity. The brain network can easily become damaged, but throughout life, new neurons are constantly being formed. Our brain, much like our sense of self², is in a constant state of flux. It is possible, but by no means guaranteed, that the network will reform. But, given that you are not having exactly the same conscious and unconsious life experiences, it seems very unlikely that the neurons will reform in exactly the same way. This does not preclude the outcome of the new neural pathways being the same (e.g. a re-increase in patience), but the micro structure of the brain will likely be different. So, the new personality gained during and post- recovery may in fact be permanent.

Vis-à-vis: if it's a vascular patient, you can tell.

¹ FAO Non-UK citizens: Wales is a country, the UK is a collection of countries comprising of England, Wales, Scotland and Northern Ireland.

² Due to neuroplasticity, if your sense of self isn't subject to review, I suggest you revisit that, but this could be hearsay. See the Hard Problem.