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Posted by on Apr 28, 2010 in Neurology, Popular culture

Bret Michaels and SAH

Bret Michaels and SAH


First: Donald Trump is “dealing with” Bret Michaels’s absence from “The Apprentice” reality show.

[Pause for universal brow mop.]

Second: The latest on the Poison singer is that he’s suffered a “minor setback” while hospitalized with a subarachnoid hemorrhage (SAH). The 47-year-old Michaels reportedly has a “lack of sodium,” or hyponatremia, reports the BBC News. The cause of Michaels’s SAH, which occurred almost 1 week ago, is evidently still unknown.*

Hyponatremia occurs in 10%-30% of patients with SAH, according to the latest AHA guidelines on the management of the condition, and is more common in patients with a poor clinical status or hydrocephalus. The condition appears to be related to the inappropriate urinary excretion of sodium. The major concern with hyponatremia in SAH is that it is associated with reduced intravascular volume, which is linked to cerebral vasospasm (see below).

To reduce the risk of hyponatremia in SAH, the guidelines recommend that large volumes of hypotonic fluids and volume contraction should be avoided. Intensive-care monitoring of the circulatory volume is also advised. When hyponatremia occurs, the administration of hypertonic saline and fludrocortisone (Florinef) is “reasonable” to achieve euvolemia.

Other issues to concern Michaels’s treating doctors are cerebral vasospasm and rebleedingboth major contributors to SAH-associated death.

Cerebral vasospasm, seen in 30%-70% of patients with SAH, typically occurs 3-5 days after the initial bleed and gradually resolves during the next 2-4 weeks. The calcium-channel blocker nimodipine (Nimotop; Bayer) has been shown to reduce the risk of poor outcomes associated with post-SAH vasospasm.

Efforts to reduce the risk of rebleeding in SAH include bed rest and the control of circulatory volume and blood pressure to some sort of equilibrium that avoids both hypertension and volume contraction. There are data suggesting that the risk of rebleeding is reduced with an early, short course of antifibrinolytic therapy (Amicar).

Among survivors of SAH, persistent deficitsincluding cognitive impairmentare common. The 3 strongest predictors of death or disability are impaired consciousness on admission, advancing age, and a large bleed.

AHA = American Heart Association.

* In about 75% of cases, subarachnoid bleeding is caused by a ruptured (eg, berry) cerebral aneurysm; and in about 20% of cases, there is not an identifiable cause. According to a 2006 review, a substantial percentage of the cases with an unidentified bleeding source are defined as idiopathic in nature. The remainder, 5%, are caused by vascular malformations, arterial dissection, sympathomimetic drugs (eg, cocaine, phenylpropanolamine), tumors, or vasculitis. Notably diabetes, which Michaels reportedly has, does not increase the risk of SAH.

From Wikipedia: Horizontal cut of CT image showing hyperdense subarachnoid blood in the basal cistern. To my knowledge, this is not Bret Michaels’s scan.

05/06/10 addendum: Although today’s FOXNews story of Bret Michaels’s release from the hospital makes it sound like the rocker was discharged to home, Michaels was actually released to a physical rehab facility, according to USA Today. The latter story makes a whole lot more sense.

Michaels SAH occurred almost 2 weeks ago, and other than the report of hyponatremia, he did not suffer any of the usual SAH-related complicationslike cerebral vasospasm or rebleeding. The cause of Michaels’s SAH was evidently never identified, and he apparently has not experienced any significant neurologic deficits. In the setting of being really unlucky, Michaels is a very, very lucky guy. So is Donald Trump, who must be peeing himself, given the possibility that Michaels may rejoin “The Apprentice.” 

bmartin (1130 Posts)

A native East Tennessean, Barbara Martin is a formerly practicing, board-certified neurologist who received her BS (psychology, summa cum laude) and MD from Duke University before completing her postgraduate training (internship, residency, fellowship) at the Hospital of the University of Pennsylvania in Philadelphia. She has worked in academia, private practice, medical publishing, drug market research, and continuing medical education (CME). For the last 3 years, she has worked in a freelance capacity as a medical writer, analyst, and consultant. Follow Dr. Barbara Martin on and Twitter.