Intracerebral hemorrhage

[Malcolm White]

Hi all, I recently returned from Jamaica where I completed my Advanced Open Water certification over a 2 week period (16 dives in total). Four days after returning back to Europe, whilst bending down to unpack a box, I noticed slurring of my voice for about 20-30 seconds. The next morning, it happened again and headed straight to the nearest A&E hospital. A CT scan showed an 8mm bleed on the left side of my brain. A second CT (with dye) showed that the bleed wasn't active. I was transferred to another hospital (with the top neurological surgeon) and was told that there was no need for surgical intervention. An MRI scan showed no deterioration. Given the position of the bleed, it did impact my speech but I had no other motor function issues. Four days later, a further CT scan showed 'significant' reduction and was allowed home.

Now, it's probably impossible to verify the cause of the bleed. We did two fairly deep dives, to about 100 feet. but I had no problem equalizing, even though I did have a wax build-up in my left ear (which was subsequently cleared using hydrogen peroxide/water rinse). My blood pressure is fairly stable (typically 135/80 or so) and I'm 62 years of age. After returning home, I also had some sinus issues.

All the dives were well within NDL with all safety stops and I had 24 hours rest prior to flying home. Given that I have no clue what caused this issue, naturally, I'm planning to give up diving rather than risk another issue (and this one could have been so much worse!)

Any medical practitioners on here care to comment?

Thanks.

 

[Duke Dive Medicine]

Malcom,

I'm sorry to hear about this. I think it's very unlikely that your bleed is connected to your dives. Was there a specific source identified, e.g. some type of aneurism? Did the neurologist offer a prognosis or mention the likelihood of it happening again?

Best regards,
DDM

 

[Malcolm White]

Thanks for the reply. There was no sign in any of the 3 CT scans and MRI scan of any other cause. I'm wondering if the left ear blockage might have contributed, given the additional pressure needed to equalize? The neuro consultant only suggested finding another pastime!

 

[Duke Dive Medicine]

Hi Malcom,

Your initial post said that you did not have difficulty equalizing. Can you confirm? Also, do you have any other medical issues aside from mild hypertension? Are you under a physician's care for anything?

Best regards,
DDM

 

[Akimbo]

I have a friend who had a cerebral hemorrhage after several years of occasional severe headaches. No imaging found a problem to explain the headaches nor did his physicians believe his blow out was related. As I understand it, all of us probably have weak blood vessels somewhere and most people die of something else first. Life is short, eat dessert first. I'm glad you are still around to enjoy them.

 

[Malcolm White]

Hi DDM, during the dives, I was never in a position where equalization was not achieved (despite almost a loss of hearing due to wax in my left ear).However, it might have required excessive nasal pressure to achieve it. I’m not under any physicians care and it’s only the mild hypertension. I was on BP tablets last year, but in the meantime, I lost 35 pounds resulting in acceptable BP.

 

[Duke Dive Medicine]

Thanks for the reply Malcom. Just to make sure, I reached out to one of our more prominent neurosurgeons for confirmation; it's unlikely that your ICH was related to your diving. Moving forward, I would recommend that you follow the advice of your care team. It's a little troubling that no source was identified, so I'm sure they have advised caution with activities that could increase your intracranial pressure.

Best regards,
DDM

 

[Malcolm White]

Considering this issue further, given that my last dive was on a Saturday lunchtime, and the first symptoms were the following Friday evening, does it seem probable that this was too long a period for the diving to be the cause?

 

[Duke Dive Medicine]

Considering this issue further, given that my last dive was on a Saturday lunchtime, and the first symptoms were the following Friday evening, does it seem probable that this was too long a period for the diving to be the cause?

Hi Malcolm, yes, that would be a reasonable conclusion, and apologies for the name misspelling earlier

Best regards,
DDM

 

[doctormike]

I am DEFINITELY not a neurosurgeon, but the six day interval makes it seem pretty unlikely that this was dive related. That having been said, it's possible to have a small aneurysm that is below the limits of imaging detection that bleeds with increased intracranial blood pressure. The actually physiology of a stroke is a bit complicated, so for background, here is my understanding.

A stroke is the death of brain tissue caused by loss of blood supply (if this is temporary, it's called at TIA). That can happen in one of three ways.

A hemorrhagic stroke happens when a small blood vessel bursts, and the downstream tissue is deprived of blood. This can be associated with a pre-existing abnormality like an aneurysm (weak dilated blood vessel) or a congenital malformation of blood vessels. High blood pressure in the cerebral circulation is a risk for that.

An embolic stroke happens when something breaks off in the bloodstream and clogs a small blood vessel in the brain. This can be from clots forming on the heart valves, from plaque on the wall of the blood vessel. It can also be an air bubble that crosses from the venous to the arterial circulation through something like a hole in the heart (PFO) - this is the feared arterial gas embolism (AGE) seen in DCI.

You can also get a stroke from a DROP in cerebral blood pressure, specifically in "watershed" areas, which are areas in the brain that are at the end of two separate blood supplies, so that they are the first to lose perfusion when the pressure drops.

With a Valsalva maneuver (to clear an ear during a dive), you might think that this would increase intracranial blood pressure and make a hemorrhagic stroke more likely. Interestingly, while the Valsalva increases overall intracranial pressure (the pressure in the cerebrospinal fluid), from my limited understanding it actually causes a DROP in intracranial blood pressure.

Hard to give a recommendation about diving in this case...