Severe Coma After Massive Hemorrhagic Stroke: A Case Study

Q: Severe Coma After Massive Hemorrhagic Stroke: A Case Study

Hello Ms. <br>Hsueh： <br>1. <br>Brainstem hemorrhage can lead to post-hemorrhagic hydrocephalus, and ventriculostomy is a reasonable medical intervention. <br>However, the timing of the surgery should be determined based on the patient's condition, so please collaborate with your

Massive hemorrhagic stroke with severe coma?

Hello, doctor! My father has a history of hypertension and has been a long-time smoker and drinker.
A month ago, he underwent gallbladder removal surgery due to gallstones, during which arrhythmia was discovered.
Two weeks after the internal medicine surgery, he followed up with a cardiologist who prescribed anticoagulants.
About ten days later, he experienced dizziness and drowsiness at 6 AM, followed by a loss of consciousness.
After about an hour, family members found him and rushed him to the hospital for emergency care.
Due to uncertainty about whether he had taken the anticoagulants, surgery or angiography could not be performed.
A CT scan indicated a large area of bleeding near the brainstem, but the exact location of the lesion was undetermined.
He was continuously given antihypertensive medications while being intubated and later admitted to the ICU on a ventilator.
Five days after the incident, the doctor performed a ventriculostomy and found that the cerebrospinal fluid drained was minimal.
He remains in a state of severe coma, relying on the ventilator for oxygen.
His blood pressure has stabilized, but he occasionally experiences fever and unstable respiratory conditions, with antibiotics continuously administered in the ICU.
Now on the 13th day, my father occasionally blinks and makes slight movements of his feet when family members call out to him, but the ICU doctors assess that his vital signs are still around 5.
I would like to ask the doctor if, under these circumstances, it is advisable to perform a "ventriculoperitoneal shunt" surgery? Additionally, since the lesion has not yet been confirmed, is there still a need for angiography? Regarding the occasional blinking and slight foot movements when family members call out to him, are these merely reflexes or could they indicate a slight improvement? I would greatly appreciate any feedback or advice from the doctor.
Thank you very much! Wishing you peace and safety.

Xue Nüshi, 40~49 year old female. Ask Date: 2024/02/20

Dr. Cai Zongzhang reply Neurology

Hello Ms.
Hsueh:
1.
Brainstem hemorrhage can lead to post-hemorrhagic hydrocephalus, and ventriculostomy is a reasonable medical intervention.
However, the timing of the surgery should be determined based on the patient's condition, so please collaborate with your physician to make a decision.

2.
The cause of the intracerebral hemorrhage can be confirmed through angiography to check for any aneurysms.
However, during the acute phase, the priority is the safety of the patient, and it may be advisable to wait until the condition stabilizes before proceeding with further examinations.

3.
Patients with brainstem hemorrhage may enter a comatose state, and responses to auditory or tactile stimuli may trigger reflexive movements, which are not necessarily indicative of conscious control by the patient.

Reply Date: 2024/02/20

More Info

I'm sorry to hear about your father's condition. It sounds like a very challenging situation for both him and your family. Let's break down the key aspects of his case and address your questions regarding his severe coma following a massive hemorrhagic stroke.

Firstly, your father's history of hypertension and his lifestyle choices, including smoking and alcohol consumption, are significant risk factors for cerebrovascular accidents (strokes). The fact that he underwent gallbladder surgery and was subsequently placed on anticoagulants raises concerns about the potential for bleeding complications, especially if he had underlying vascular issues.

In cases of massive hemorrhagic stroke, particularly when the bleeding is near the brainstem, the prognosis can be quite serious. The brainstem is responsible for many vital functions, including heart rate, breathing, and consciousness. The presence of a large hematoma can lead to increased intracranial pressure, which may necessitate interventions such as a ventriculostomy (brain ventricular drainage) to relieve pressure and monitor intracranial pressure.

Regarding your specific questions:
1. Ventriculoperitoneal Shunt Surgery: The decision to proceed with a ventriculoperitoneal shunt (VP shunt) or any other surgical intervention should be made by the neurosurgical team based on the overall clinical picture, including the extent of the hemorrhage, the patient's neurological status, and the potential for recovery. If your father is still in a state of severe coma with minimal response, the risks and benefits of further surgical intervention need to be carefully weighed. The fact that he has shown some reflexive movements, such as eyelid blinking and foot movements, could indicate some preserved brain function, but these movements can also be reflexive and not necessarily indicative of conscious awareness or recovery.

2. Need for Angiography: If the source of the hemorrhage has not been identified, performing a cerebral angiogram may be warranted to assess for any vascular malformations, such as arteriovenous malformations (AVMs) or aneurysms, which could have caused the bleeding. This imaging can provide critical information that may influence treatment decisions. However, the risks associated with the procedure, especially in a patient who is unstable, must be considered.

3. Reflexive Movements vs. Conscious Response: The movements you describe—eyelid blinking and foot movements—can be confusing. While they may suggest some level of neurological function, they are often reflexive and do not necessarily indicate that the patient is aware of their surroundings or able to respond to commands. Neurologists often use standardized scales, such as the Glasgow Coma Scale (GCS), to assess the level of consciousness and responsiveness in comatose patients.
In summary, your father's situation is complex and requires a multidisciplinary approach involving neurologists, neurosurgeons, and critical care specialists. Continuous monitoring and supportive care in the ICU are crucial. It is essential to maintain open communication with the medical team to understand the rationale behind their decisions and the potential for recovery.
I hope this information helps clarify some of your concerns. Please take care of yourself and your family during this difficult time.

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