By Mohammad Hossein Najmabadi, anesthesiologist and ICU specialist
Translated By Roya Monajem, Tehran

Translator's note

One of the major plagues of narrow-mindedness and illiteracy of rulers is forced or self-chosen isolation of learned and experienced professionals in all fields. Alas! What an increasing number of such remarkable individuals in all fields of knowledge and arts are now living in seclusion throughout this ancient land.

Dr. M.H Najmabadi can aptly be called the father of intensive care unit (ICU) of Iran. Graduated from Düsseldorf University, Najmabadi returned to Iran in 1974 and founded the intensive care unit of Tehran Heart Hospital (before the revolution), the ICU of Khatam-ol-anbia Hospital, the heart surgery and ICU of Shariati and Sorkheh Hesar General Hospitals with the first pediatric heart surgery department in the latter. He has published many research papers and articles in different international and national journals. His first book Lung in Shock written in German (1988) (with the Persian translation appearing in 1991) was well-received in German medical circles. Pediatric Heart Surgery (1998) the result of his 10 years practice in Sorkeh Hesar Hospital is now a reference book in this field. According to an anesthesiologist colleague his novel Sara'b-e Darma'n (The Mirage of Cure) (2004) is also a remarkable teaching guide in the field of anesthesia. Najmabadi is also a professional photographer having held a few solo photography exhibitions at Golestan art gallery (Tehran). He spent many years studying the famous mosque Sheikh Lotfollah in the ancient city of Esfahan (Isfahan), taking the most beautiful and unique photographs of this magnificent Sanctuary of Light as he calls it in a bilingual book he later published (2002).

In the following article medical terms are avoided to make it understandable for a wider range of readers.

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You brother, you are all thoughts
The rest of you are just bones and sinews

Molana-Rumi

According to the prevalent medical belief, the main cause of brain stroke (cerebrovascular infarction) is obstruction of blood vessels by blood clots (embolism) or bleeding (hemorrhage).Overwork and hyperactivity of this organ is never considered as a major causing factor in these injuries. This is because brain is not seen as an organ which works and thus consumes oxygen like all other organs of the body. Why? The reason lies in the fact that the outcome of all other organs can be measured in laboratories as some kind of substance, while what brain (or at least some parts of it) produces (thoughts, fantasies, daydreams and...) are not material in the same sense of the word and thus are not measurable as such. When heart stops working due to lack of oxygen we speak of heart stroke which means heart muscles cease functioning due to oxygen deficiency. Similarly excessive thinking, worrying, grieving and the like which is an index of brain hyperactivity can very well lead to oxygen deficiency and bring about the same effect, that is brain stroke.

It is true that the correlation between stress and heart and brain strokes is known for a long time now, but stress is normally seen as a factor increasing the blood pressure and not as a product of brain hyperactivity. What does stress actually mean other than too much mental pressure, therefore excessive thinking?

With a weight of 1300-1500g, brain allocates 20 percent of the heart (cardiac) output to itself. This shows that in comparison to its weight and the amount of blood it receives, brain consumes oxygen more than all other organs (50ml of 250ml of oxygen inspired per minute). This extraordinary high oxygen consumption is one of the main features of this organ which can also be shown by comparative measurement of the amount of blood oxygen leaving the brain and other organs. Another characteristic feature of the brain as the sultan of the body is that when cardiac output falls as the result of cardiac insufficiency, the sultan takes possession of all cardiac output by issuing the order: Shut down blood circulation to all other organs except the heart.

In patients who develop a blood clot (embolism) and thus cardiac insufficiency as it sometimes happens after Mitral valve surgery, cardiac output may drop to 800 ml/minute (instead of 4000 to 5000 ml/minute under normal conditions). In all these patients although skin becomes marble white due to lack of blood circulation, they remain conscious in the sense that they continue breathing without outside help. This indicates and proves that the brain is receiving enough blood to take care of the system.

An important point which is normally neglected is that during any kind of hyperactivity organs do not wait to receive more blood in order to do the extra work. That's why the rate of heart stroke on tennis playgrounds and during jogging is considerable. The heart does the extra work hoping to receive the extra oxygen later. However, if the heart muscle fails to receive the extra oxygen due to vascular insufficiency, it will suffer from oxygen deficiency which results in heart stroke or infarction. Exactly the same thing can happen to the brain too.

As mentioned before, there is a direct meaningful correlation between stress and the rate of brain stroke. Now if we take stress as the sign of brain hyperactivity rather than a factor increasing the blood pressure, then brain infarction can very well be due to oxygen insufficiency rather than embolism or hemorrhage resulting from high blood pressure which is what medical specialists unanimously believe. But this is only a hypothesis. Stress means mental pressure which in turn means excessive thinking reflecting hyperactivity of the brain. Hyperactivity in all organs, including the brain is accompanied with blood and oxygen deficiency leading to anaerobic respiration (i.e. energy production without the use of oxygen). Later when blood circulation is resumed, the corresponding organ begins to swell and enlarge. Therefore, its volume increases. Now while such an increase in volume has no serious outcomes in case of other tissues like those of the heart and kidneys for example, in brain which is imprisoned in the skull, the situation is different. The increase in volume exerts more pressure on the brain tissue, thereby increasing blood pressure in the skull which in turn leads to blood insufficiency and therefore more swelling. For example, in patients who following cardiac surgery suffer from air embolism, the arterial pressure of the brain can reach 400 mm of mercury. Under such high pressure produced by swelling of the brain, it is obvious that blood can no longer enter arteries of the brain. Such cases, whose number is quite significant seriously rules out another questionable common hypothesis that the brain can not endure blood insufficiency more than three minutes. If we manage to prevent the above sequel by taking the appropriate measures in time, these patients can very well survive even longer periods of blood insufficiencies. On contrary, when appropriate measures are not taken in time, the brain can stop working if it does not receive blood for only one minute.

In cases of heart arrest when the brain does not receive enough blood, thereby switching to anaerobic respiration, swelling and enlargement occurs when blood circulation is resumed. This is when complications such as convulsion start if appropriate measures are not taken to stop brain functioning. Brain is put into complete rest in the following two ways:

1) Intravenous injection of a barbiturate like Phenobarbital (Luminal) at high doses (2-3mg/kg); [1]

2) Bringing down the body temperature to 28 Centigrade by application of water mattress.

The hypothesis of irreversible changes occurring in the brain three minutes after the heart arrest is very much questionable as the case of a young man struck by electricity showed. From the time he was struck and fell down a ladder and went unconscious because of holding bare electricity wires to the time he was taken to the hospital, resuscitated and immediately put into complete rest by applying the above procedure, it took at least 20 minutes. (The case was so incredible that we did recreate the scene to find out exactly for how long he had been unconscious). After six weeks of keeping him under the above conditions and then gradual reduction of the medicine, warming up his body back to the normal temperature and finally taking him off the artificial respirator, the patient left the hospital without any so-called irreversible lesions. Another similar case was that of a 16 years old girl who suffered acute air embolism during cardiac surgery. She too recovered after four weeks with the above procedure without any side-effects. In other words, if we succeed to control swelling and inflammation (without paralyzing the brain), the organ can endure oxygen insufficiency for a longer time than it is believed. From what is said it is clear that it is absolutely wrong to give up on patients for the mere reason that the brain can not endure more than three minutes of oxygen insufficiency without some irreversible side-effects.

Another very important point often ignored or neglected here is that as convulsion means oxygen deficiency, what is important is to stop brain activity at any cost. Muscle relaxants and morphine, the drugs usually prescribed can not bring about total inactivity (complete rest) of the brain. In other words, the thinking function of the brain is not stopped by the use of above drugs. Good and bad thoughts at this stage make no difference. For a better understanding of the point we wish to make here, let us again take the better known example of the heart. The aim of complete rest prescribed for cardiac patients is to decrease oxygen consumption by the heart muscle.

In case of the brain, the situation is much more complicated as it is not as easy to stop its activity in terms of thinking. Any person, who spends the whole day in a stressful way, can not sleep well at night either. In other words, oxygen consumption does not decrease to a sufficient amount even during sleep in order to give a good rest to the brain. Another difference between these two organs is that unlike heart which produces pain in case of blood-oxygen insufficiency, similar warning mechanism does not exist in the brain at least not until the swelling and subsequent increase in volume reaches the stage to stimulate sensory receptors of pia and dura matters. The aim of artificial coma is to prevent the activity of the brain which subsequently reduces swelling and thus protects the brain.

It should be noted that any swelling and inflammation if continues for long leads to calcification of the corresponding tissue.

And this is the third point to bring up in this article. Hyperactivity of the brain in terms of excessive thinking when continued for a long time causes oxygen insufficiency, swelling and inflammation with the end result of calcification. According to latest discoveries in brain research it has been discovered that different parts of the brain do calcify as the result of aging, Alzheimer, Parkinson Disease and Down Syndrome. [2] The supportive evidence for the presence of a direct correlation between inflammation and subsequent calcification of the brain tissue is provided by the fact that the incidence of Alzheimer in patients suffering from Rheumatoid Arthritis is significantly lower, due to anti-inflammatory drugs they use.[3]

To conclude: Although brain is a unique organ from many aspects, it is exactly like all our other organs in regard to hyperactivity and oxygen consumption. What makes us to ignore this fact is the immaterial nature of its products (thoughts) compared to those of our other organs.

From what was said above not only excessive thinking increases the risk of brain stroke, but also Alzheimer and Parkinson Disease. So beware!

... Payvand News - 10/23/09 ... --