Sharon's Prognosis Poor, Experts Say

The bleeding in the brain suffered by Ariel Sharon earlier this week and its subsequent complications make his prognosis poor, with little chance he will be left undamaged if he survives.

That was the conclusion two experts reached yesterday based on studies of patients roughly similar to the Israeli prime minister, but without specific knowledge of his case.

"The chance that he is going to be normal is very low. There is a good chance that he would be left with a significant deficit," said Francois Aldrich, a vascular neurosurgeon at the University of Maryland Medical Center in Baltimore.

"What is the chance that he will be left with some disability? It is highly likely. What is the chance that he will return to normal? It is highly unlikely," said Daniel F. Hanley Jr., a neurologist at Johns Hopkins Hospital whose research includes studies of treatment of intracranial hemorrhage, or bleeding inside the skull.

The risk of death is high. According to a study published in 2003, 42 percent of people with spontaneous bleeding in the brain die within one month. Sharon has several risk factors -- principally his age -- that may raise his risk even higher. Virtually any form of ill health -- obesity, hypertension, smoking, diabetes, kidney or liver problems -- is likely to worsen the outcome.

Few details of Sharon's initial problem and its treatment have been released, making it difficult to know exactly what he has suffered, let alone gauge the probable severity of his brain damage.

The surgeons have not described the size of the blood clot they removed this week after Sharon's initial bleeding episode. Neither have they described where in the brain he bled, nor whether it was on the "dominant" side, which governs language. Large clots deep in the brain in the dominant hemisphere, or half, of the brain carry the gravest prognosis.

Sharon's bleeding was at least partly the result of being on an anticoagulant drug, which he was given to prevent recurrence of a small stroke he suffered last month caused by a blood clot that went to his brain. The effect of that medicine had to be reversed, and his blood clotting returned to normal, before he underwent surgery, Aldrich noted.

"We cannot do surgery if we do not have normal coagulation. That is an absolute," he said.

The fact that doctors chose to operate suggests, at least indirectly, that the bleeding was extensive and the clot large enough to be compressing brain tissue to a degree that could destroy it. The fact that Sharon had two operations on the first day he was hospitalized, Jan. 4, also suggests that the bleeding was difficult to control.

The reason for yesterday's operation -- the third -- was reportedly to lower dangerously high pressure inside his skull. That increased pressure could have been caused by more bleeding or by a blockage in the flow of cerebrospinal fluid, the watery substance that bathes and cushions the brain and spinal cord.

There are four reservoirs, called ventricles, in which the fluid collects as it slowly circulates. Sometimes cerebral hemorrhages rupture into one of them. When blood clots inside a ventricle, it can block the flow of the fluid. The pressure is relieved by drawing off fluid and then temporarily placing a plastic catheter that allows the surgeons to remove more if necessary.

Sometimes the blockage resolves but often it does not. Doctors then put in a permanent tube, called a shunt, that drains excess fluid from the ventricle into a vein.

Sharon was reportedly in a coma intentionally induced by drugs. Doctors traditionally use barbiturates to accomplish this because that family of medicines lowers pressure inside the brain at the same time it produces unconsciousness.

The best treatment for patients who bleed into the brain is a matter of controversy and intensive research.

A long-awaited study involving about 1,000 patients in 27 countries was published in the journal the Lancet a year ago this month. Half the patients were randomly assigned to get immediate surgery to remove the clot.

The other half were randomly assigned to receive drugs and other interventions and were operated on only if things became worse.

Six months after their hemorrhages, 26 percent of the people who underwent immediate surgery "had a favorable outcome," compared with 24 percent whose initial treatment was more conservative. In statistical terms, there was no difference between the two groups.

Nevertheless, Hanley said, it is possible that some subgroups of patients may benefit from early surgery, and research to try to identify them goes on.