[Event "www.ChessWorld.net server game"]
[Site "www.ChessWorld.net "]
[Date "2013.10.31"]
[Round "NA"]
[White "Sarfati_FM"]
[Black "arted"]
[Result "1-0"]
[Termination "Black king mated"]
[WhiteElo "2240"]
[BlackElo "1493"]
[Mode "ICS"]
[DateLastMove "2013.11.5"]
[Board "9012665"]

Game Collection: Craig Laird at the 85th NZ Ch

Capa had what is commonly called a hypertensive thalamic hemorrhage. Most of the big ones I have seen (such as described) are invariably fatal.

Small background: The ascending reticular activating system are neuronal cell bodies that run from the upper pons to mesencephalon to the diencephalon on either side of the ventricular system (4th ventricle, aqueduct of sylvius, and third ventricle). Severe damage to an ipsilateral aspect of it results in permanent coma. Apparently Capa had a big one (5cm by 5cm in the thalamus is big) on the right thalamus. <Right thalamus almost totally destroyed, with some pieces in the anterior horn of the right lateral ventricle. Where the thalamus was, there was a hematoma 5 cm wide and 5 cm high.> The last statement implies that the volume was approximately 60cc.

The big thalamic hemorrhages typically rupture into the medial adjacent third ventricle, which is why <The whole ventricular system was flooded with blood>

The internal capsule where the motor controlling cortico spinal tract runs is adjacent to the thalamus and further down crosses to the opposite side in the cervico medullary junction, and so the contralateral side is paralyzed. Thus <paralyzed his left face, left side>

I don't understand this though: <with the left pupil dilated and unresponsive to light.> It should be the ipsilateral pupil that should dilate first, which is the right pupil in this case. Probably a typo in the autopsy report? The dilated pupil indicates that the uncus, the medial part of the temporal lobe, had herniated into the tentorial fossa because of pressure from the blood clot.

In any case, once a patient comes in comatose with a dilated pupil in a case of hypertensive thalamic hemorrhage with rupture into the ventricles, he is doomed. I have never seen one survive. I have operated on perhaps a dozen of these, the last one a few months ago, and I try to remove the hemorrhage (usually via a large frontal cortisectomy which is the least bloody approach), and also the drain the bloody CSF from the ventricular system via a tube ventriculostomy, but every one of the cases with the large hemorrhages have died or gone into a persistent vegetative state. (The results are so discouraging that nowadays, I just do it if the family insists, and it's really just to console them with the thought that everything including an operation was done.)

The smaller ones that rupture into the ventricular system usually result in hydrocephalus, and I usually do emergency drainage via a tube ventriculostomy. Most of them survive, but usually with hemiparesis of the contralateral side. However, in Capa's case, it was a huge bleed.

Such a hemorrhagic stroke usually occurs after years and years of hypertension. Small micro aneurysms develop in thalamostriate arteries, and if the hypertension remains uncontrolled, they typically eventually rupture, and you get a thalamic hemorrhage. This comprises around 15% of hypertensive hemorrhage cases, but the larger ones carry a very poor prognosis.

I hope Capa became unconscious quickly. Patients with brain hemorrhages suffer from the biggest intolerable headache of their lives, and the survivors who happen to have no amnesia tell me that they felt that their heads were exploding.

Unfortunately, during that era, there was no effective anti hypertensive drug. Unlike most other ailments, headaches associated with hypertension severely affects concentration and thus chess playing ability. I believe that Capa first became symptomatic in 1924, when he sought medical consult during the New York tournament. Beginning that year, he began missing tactics in his calculations, a tendency that grew worse later in his career.

<19M drove his motorcycle into a parked truck 3 days ago in a neighboring province. Comatose, he was referred next day to me. I intubated him in PrH2 ER and transferred him to the public CiH because of lack of family finances. He exhibited the rare Kernohan's sign. He had an acute subdural hematoma on his right hemisphere, yet his left pupil was more dilated than his right (3mm and 2.5mm respectively).>

Yes, but there was a time delay. He came from a neighboring province that has no Neurosurgeons.

The fastest and cleanest but late brain operation always 'loses' to the slowest and messiest but early one, all other things being equal.

<I didn't realize that an external injury could produce something similar to the deeply internal injury of a hypertensive cerebral hemorrhage.>

Sometimes they do. A trauma may cause basal ganglia hemorrhages, thalamic hemorrhages, mid brain hemorrhages if they damage the same blood vessel whose ruptures are usually associated with hemorrhagic strokes.

I do not know exactly what disease GM Bukavsin suffered from. Based on what I have read from his page, He had a stroke. A stroke below age 40 is regarded as 'stroke in the young', and the most common lethal one is an arterio-venous malformation.

Unfortunately you are right. It's a congenital ticking time bomb in an apparently healthy person. A CT scan usually shows mass of whitish worm-like structures inside the brain.

I see them sporadically and have operated on perhaps a dozen or so (can't recall the exact number anymore). When you open up the brain, you see large abnormal vessels that spurt out blood if you cut them. The book recommends clipping them, and I did so when I was a resident. In my place, there are no clips, but I have found out that cauterizing the feeder vessels carefully with bipolar suffices to control the bleeding. The hard part is to visually expose these vessels properly. If you cut them while they are still buried deep in brain tissue, you will have blood spurting out and painting your field an opaque red. You realize to your horror that you don't know exactly where the bleeding is coming from, and that you can't cauterize what you do not accurately see. You just have to suction the blood as fast as you can and brain tissue as well in order to visually expose the buried vessels, before your patient dies on you of exsanguination. What I do is to suction a bit of brain around the undisturbed vessels in order to visually expose them properly and make sure I don't cut them by accident or carelessness.

As a rule, the patient is young, more males than females, and leading a normal life, often quite active as most young people are. Then they get intolerable headaches, and lose consciousness. In the worst cases, they just drop down unconscious without any warning sign.