Prognosis - Hemmhoragic stroke

[ericb]

My mother, a healthy 61-year old, was admitted to ER after a mild stroke at her water aerobics class.  Her condition deteriorated quickly in the ER as the stroke was hemmhoragic. It took hours to flush the Coumadin she had been taking for a thrombosis 2 years earlier.

The bleed was significant, 5 cm, producing swelling and displacement and eventually entering the ventricles – all of them.  A ventriculostomy done at right frontal lobe the first evening drained a small amount of fluid over several days, but ICP was low (bleeding had diffused?).  EEG showed mild slowing from first day to the next, but nothing particularly bad.  At two weeks she is medically stable but has not recovered from the coma she entered the first day.  The medical team is of two minds: the neurosurgeon remains convinced she will emerge from the coma, the neurologist believes there’s been significant brain stem trauma from blood in the ventricles.  We are now considering a move from ICU to a TBI rehab facility, should they accept her as a patient upon evaluation next week.

The basic questions are:
- what is the prognosis, specifically for emerging from the coma?
- What diagnostics are appropriate, other than an evaluation of neuro function, to determine extent/ type of brain stem damage?
- Is there any sort of new/ cutting edge procedure or treatment for improving/ stimulating brain stem function which should be considered?
- Would care in a rehab program focused on coma recovery be of any value if the issue is brain stem function rather than repathing cognitive circuits?

[CCF-Neuro-M.D.-JT]

Very sorry to hear about your mother's recent stroke. I can imagine how difficult it must be for you and your family at this time. Unfortunately, I cannot make an accurate prognosis without knowing exactly where the bleed was originally, how extensive in size it is (usually has 3 measurements: width/length/depth for volume estimation), and what her neuro examination looked like at the onset and now. Generally speaking, we can estimate the 30day mortality survival rate of a patient with intracerebral hemorrhage with the Glascow Coma scale, hemorrhage size, and patient age. But again, the first things I mentioned are all very important (especially the neuro exam findings) in helping to determine how severe her coma is. EEG and Evoke potentials are both tests that can also evaluate the level of coma she is in.

If there is any doubt as to her potential recovery, I would consider putting her in rehab to wait and see what she does. Please keep in mind that I have not personally reviewed your mother's films nor examined her. Some of the things that we do at the Cleveland CLinic for coma patients include medications such as ritalin or amantadine. There are centers around the world that are experimentally using deep brain stimulation in patients with coma, in which a small electrode is placed inside the brain and electrically stimulated. The reports vary from no improvement at all to emergence from coma. BUt there is not enough evidence right now that this will work on all coma patients. Talk to your doctors again, and tell them you need help understanding everything so that you can make an informed decision about further treatment. An important question that you could ask them is that if your mother does wake up, what kind of neurological recovery can she expect. WIll she be able to walk, talk, interact with family members, lead an independent life, etc... ANd then think about what she would have wanted. Best of luck to you and your family.

[patches748]

I truly wish your mother, you and your family well.  May God be with all of you and you are all in my prayers.