The Bee Foundation has awarded the 2017 Brain Aneurysm Research Grant to two researchers, Jennifer Kim, a neurocritical care fellow at Mass General Hospital, and Justin Mascitelli, cerebrovascular fellow at the Barrow Neurological Institute in Phoenix. We recently spoke with Dr. Kim to learn more about her research project.
Tell us a little about yourself.
Currently, I am a neuro critical care fellow at Mass General Hospital. I am also currently in training at Brigham and Women’s Hospital. I have had a research interest for a long period of time. I got a PhD at Brown University conducting studies on mice looking at mechanisms of seizure generation. As I started a neurology residency, I became more interested in the human population, but still within the electrophysiology field, which is how I came to thinking about the utility of using electroencephalography (EEG) in our patient populations within the intensive care unit (ICU).
Our particular projects are interested in looking at the subarachnoid hemorrhage population and whether we can use this particular technique to identify patients who are at high risk for secondary injury.
Is a subarachnoid hemorrhage different than a brain aneurysm?
Subarachnoid hemorrhage is basically a bleed in the brain that occurs in the space right outside the brain (subarachnoid space). It’s related to brain aneurysms in that aside from trauma, the most common cause of patients having bleeding in that part of the skull is because of brain aneurysms. So when we talk about brain aneurysms bleeding, that’s the part of the head where the aneurysm bleeds into.
Why did you get involved with subarachnoid hemorrhaging specifically?
It’s an interesting population to take care of clinically. They tend to be some of the sickest patients we take care of and they end up staying in the neurocritical care units for a long period of time, and they are at risk for a lot of different consequences. For those reasons, I was interested in helping to figure out how we can minimize the neurologic damage that occurs in these patients. In a general sense, they are a patient population that provides a good opportunity for monitoring and to gather information to see if there is utility in using the EEG technique.
Additionally on a personal level, my uncle died of subarachnoid hemorrhage so I also have a personal reason to help prevent that kind of tragedy from happening to other families – similar to the founders of The Bee Foundation, who also lost a family member to an aneurysm.
It’s scary how that happens so often, and it’s usually a surprise when it does. What is the name of the research project for which you received the grant?
Identifying electroencephalographic patterns to predict patients at high risk for delayed cerebral ischemia after subarachnoid hemorrhage.
That’s a complicated title – can you give us a high-level overview of what you’ll be studying?
EEG is a method by which to measure brain activity, or brain waves, in patients, done at the bedside, and is noninvasive. Data is collected on patients with subarachnoid hemorrhage, and what we want to do is prevent one of the worst secondary injuries that happens in this patient population, which is called delayed cerebral ischemia. What delayed cerebral ischemia is, for reasons unknown, some patients who experience subarachnoid hemorrhage, end up getting secondary strokes. These strokes obviously weren’t a part of their initial injury, but these strokes damage even more brain tissue and lead to more neurologic deficits and disabilities in the patients’ recoveries. What we want to do is try our best to prevent this secondary ischemia from happening to lessen the burden of neurologic injury that a patient experiences during their recovery period.
How will your research impact the landscape of preventive brain aneurysm research – maybe eventually for primary injury rather than just for secondary?
Primary prevention for subarachnoid hemorrhage is a difficult and interesting problem. We may be able to utilize some information with EEG to try to help identify early injury; however, I don’t think it would apply necessarily to preventing primary subarachnoid hemorrhage because most people don’t know they have a brain aneurysm to begin with. Their first presentation to a medical setting is when they have the bleed itself. The EEG will hopefully help identify risk markers early on for preventing further complications, but in terms of preventing primary injury I think that that’s a little bit harder. People are really interested in looking at what other risk factors are that can be identified in the general population, but because it’s so infrequent, screening the general population using imaging is not the most cost effective. It’s a separate problem EEG unfortunately can’t address. Many patients don’t survive initial bleed, but for those that do, my hope is that using EEG in patients who are able to make it to the hospital, especially if they have a small initial bleed, can prevent or identify markers for those that are at high risk for further consequences. Our goal is to use this message to help skirt those complications.
What are the ideal outcomes of the study?
The ideal outcome of the study would be to identify within the EEG some brain activity patterns that are abnormal, that are distinct in the patients that are at highest risk for the delayed cerebral ischemia. If we can identify that sub population before the secondary strokes happen, we can work towards treatment interventions and more intense monitoring to try to help prevent secondary strokes from happening. Again just limiting the overall disability these patients experience in their recovery process.
Assuming successful outcomes, what is the next step to advance your research?
There are two different directions. First, in terms of human based research – using these markers to identify the subset of high risk patients, and to better evaluate treatment interventions. One issue of aggressive treatments is possibly exposing low risk patients to unnecessary risk and side effects of treatments. We would like to limit treatment interventions to those identified as high risk to decide what are the most effective treatments to prevent secondary injury. The second direction would be to look mechanistically at the abnormal brain activity patterns and see how they relate to the secondary injury/strokes. Are the patterns happening as a marker or side effect, or perhaps more likely – the initial injury caused abnormal activity, and the activity itself is actually what causes more brain tissue damage by increasing the supply-demand mismatch. If you have initially injured brain tissue with abnormal activity patterns, that abnormal pattern is utilizing a lot of energy. The already sick brain tissue can’t compensate for the extra demand in energy and becomes more ischemic, or hungrier, for oxygen and nutrients and suffers more damage.
I would like to do more work to translate it from human testing to testing in some animal models, using other techniques on rats and mice.
What do you think needs to be done to better educate people – primary care providers as well as those not in the medical field – about the risks and warning signs of brain aneurysms (initial injury)?
I think that primary care providers are very important in helping to screen patients for these aneurysms. The main risk factors they can identify are whether there are familial patterns and history of brain aneurysms because it’s a known risk factor for other family members having aneurysms. We don’t understand all of the genetics behind that, but it’s an easy risk factor that primary care physicians should be educated about. Most medical schools educate everyone about these but reinforcing that within the primary care field is helpful.
In terms of public awareness, a lot of people have headaches and it’s easy to ignore headaches and think it’s a one off thing, but often “worst headache of life” is the catchphrase sign of subarachnoid hemorrhage. And if we can identify patients early on with that worst headache and what we call the sentinel bleed, or the small initial bleed, then perhaps those people can be more carefully screened and referred appropriately by their primary care physicians or taken to the emergency room. Then we can provide better care to those patients and ideal treat the brain aneurysms prior to a life threatening rupture.
How can people outside the medical field best support brain aneurysm awareness and research?
Social media is a really powerful outlet for educating the general population about these kinds of things. For stroke we have a big campaign – FAST (face, arm, speech, time) – identifying the problem and getting the person to the hospital to minimize damage experienced by a patient that has a stroke. This campaign has helped alter awareness and care. Stroke is a time sensitive disease, and if you get to the hospital soon enough there are great interventions we can offer patients. If we can figure out a similar campaign like “worst headache of life” for people realizing a really bad headache unlike a typical headache is not normal, and they should seek care, it will help bring people more appropriately to medical attention.
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