Father is in a deep coma. Carotid block. Some basic reflexes.
Person's Gender: Male
Person's Age: 65
Currently in intensive care. Stroke, carotid artery blocked. Occurred approx 24 hours ago.
CT Scan + MRI seem to show diffuse swelling to the right brain. Still remains unconscious. Medication to stabilize blood pressure.
Cornea reflex active. Gag reflex active. Eyes both non-responsive. One began dilated. Now both dilated. They have both gone considerably down in overall size.
Input/second opinion is needed. We understand the grim scenario and typical results.
This is Dr Sathya and I am very glad to help you with your question.
First of all sorry to see that your dad had a massive stroke.
You have mentioned that you already are aware of the grim scenario & the typical results so it is not clear the second opinion/inputs you are looking for here is about the prognosis, or it is related to other aspects.
If you are looking for a treatment that could significantly help him then unfortunately there are no such treatments available. He has swelling of the brain and treatments like Mannitol intravenous infusion are tried but they generally do not change the overall prognosis much.
He has lots of brain stem reflexes still intact which means that his brain stem is still functional to some extent. However I am not sure whether he will be able to breath on his own at this moment and I guess he is on ventilator too. And the dilatation of pupils generally indicates not a good prognosis.
His continued comatose state too is not a good sign either.
Some patients, even after a massive stroke survive the attack, however after such big strokes it is unusual for patients to regain their full prestroke status. Patients with this type of big strokes will be left with lots of residual deficits including cognitive dysfunction/speech difficulties, motor paralysis and very poor quality of life.
In these situations generally families wait for about 3 days or so, if during that time patients do not regain consciousness then it is considered as the prognosis is going to be very grim and a decision will be taken whether to continue with life sustaining measures or not. Of course there are various legal & ethical issues related with these decisions including what the "living will" of the patient tells etc. Since patients cannot make any decisions in these states the legal power of attorney will make decisions for the patient.
If you have any additional questions do not hesitate to discuss them with me further.
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Hello thank you for responding.
You are welcome.
If there has been brain damage what signs or symptoms come next? His blood pressure is good.His heart rate is at 90-100 from the 40-50 it was for the past 12 hours.
Is he receiving any treatments to maintain the blood pressure?
Okay then that can explain why the vital signs like BP etc are good.
But his scan has showed massive stroke, agree?
He is still comatose
yes they said there was blockage to the right side and diffuse swelling
Yes, I have this information.
why the high heart rate?
Heart rate may be related to autonomic instability
excessive adrenergic response to stroke related stress
adrenaline increases heart rate
there may be other reasons too
And 90 - 100 is not very high
Up to 100 is considered normal unless his prestroke base like was much different
Other reasons I mentioned any electrolyte problems, medication side effects etc to explain high heart rate
What might we anticipate during the next 24 - 48 hours? It's been 24 since
As I had mentioned above he had a massive stroke so we cannot really tell how this will progress. Patients may survive but may be left with severe disabilities.
He was walking and talking and then he had a cardiac arrest twice before getting to hospital. they placed a stent in in a narrow artery - and then the stroke?
the mri showed no blood flow - does that automatically mean brain damage?
Well I guess the investigations might have revealed the cause for stroke already, agree? Seems he had carotid block. The cardiac arrest might have produced clot in the heart that eventually reached the carotid artery.
The mri finding corresponds to the carotid block, and that is what caused the stroke.
and that blockage in carotid automatically results in brain damage?
Yes, he has developed the stroke from this blockage.
they said there was not "that much" swelling - just that blockage and brain cells would be dead
can they tell the brain has died from the mri- no contrasting done
The mri did show the stroke & some swelling, agree? and he is comatose too, and it implies the brain damage is severe.
what do we do now? keep giving him blood pressure medicine and wait?
contrast is not necessary
Generally at least about 3 days are given
to know the prognosis better
If at that time he stll remains comatose then prognosis is not good
should we get any more brain scans?
MRI without contrast is enough to show that there is brain damage (about your earlier question)
Brain scans will not help now
There is already enough information
ok thank you - you have been more informative than all here
You are welcome, I wish all the best!
one last question.
if he should crash should we revive
That is very important question
and give the three days
It depends upon his living will
If he crashes his future prognosis is very bad
So if he did not want to revive then it is appropriate not to revive
what do we do in 3 days if nothing changes?
remove blood pressure med?
At the end of about 3 days depending upon his response further decisions will be made. If things remain same (means he is still comatose) then a meeting generally takes place with his family dr & neurologists.
At that moment these drs will convey you family members about the poor prognosis
You guys will make final decision
3 days is reasonable to best determine prognosis
about discontinuing life sustaining measures
Yes, in these circumstances, because he is comatose
ok thank you again.
You are welcome, all the best!
American Board Certified Neurologist, Internal Medicine