Stroke-Related Brain Edema: Treatment Options and Risks

Q: Stroke-Related Brain Edema: Treatment Options and Risks

Hello, based on your description： a. <br>Generally speaking, if a CT scan has confirmed a diagnosis of ischemic stroke, this diagnosis is usually sufficient, and the treatment approach is largely determined. <br>b. <br>To further confirm the area of infarction, an MRI (Magnetic R

Cerebral edema following a stroke?

Hello, my aunt has been hospitalized due to a stroke.
A CT scan of her brain shows an area of shadow (edema).
When she was first admitted, she was conscious and able to talk to family members, but in the past two days, she has become unconscious (although her breathing speeds up when family members talk to her, suggesting she can hear).
Currently, the treatment involves hyperbaric oxygen therapy every other day.
I have two questions:
1.
The hospital has only performed a CT scan and has not conducted an angiogram, so they are unclear about where the embolism is located.
Given her current comatose state, would administering a contrast agent for an angiogram pose a risk to her life?
2.
My aunt is in her eighties and has a pacemaker.
Given her condition, would it be appropriate to place a ventricular drain to remove excess fluid into the abdominal cavity? Currently, she is only receiving hyperbaric oxygen therapy, and her condition seems to be worsening, which feels like waiting for her to pass away.
I would like to know if there are more aggressive treatment options suitable for her.
Thank you.

dy, 30~39 year old female. Ask Date: 2015/04/21

Dr. Lai Zhaokang reply Neurosurgery

Hello, based on your description: a.
Generally speaking, if a CT scan has confirmed a diagnosis of ischemic stroke, this diagnosis is usually sufficient, and the treatment approach is largely determined.
b.
To further confirm the area of infarction, an MRI (Magnetic Resonance Imaging) can be performed.
However, since your aunt has a pacemaker, an MRI is generally not suitable due to the strong magnetic fields that may interfere with the cardiac pacemaker.
c.
Cerebral angiography is an invasive procedure that carries certain risks.
It is typically not necessary unless the physician determines that it is required based on the patient's condition.
d.
While determining the location of the infarct is valuable for prognosis, it does not significantly benefit the actual treatment direction.
If the physician assesses that the patient is suitable for intervention within the golden window, medication may be administered to help restore blood flow (though this carries risks).
If other cerebral vessels are occluded, they remain blocked, and it is not possible to prevent the current infarction; the focus will be on managing the sequelae of brain damage and preventing future strokes.
e.
Whether to perform a ventriculoperitoneal shunt surgery and the associated risks should be discussed with your neurosurgeon.
f.
Stroke is the third leading cause of death in Taiwan.
The average life expectancy for women in Taiwan is currently around 80 years.
Given your aunt's pre-existing chronic conditions, her prognosis is not optimistic.
From another perspective, this also means her life expectancy is close to that of most Taiwanese women.
Additionally, being in a coma may indicate a state of peace without suffering.
Therefore, the decision to pursue aggressive life-saving measures should be made with wisdom by the family.
I hope this information is helpful to you.

Reply Date: 2015/04/21

More Info

Understanding stroke-related brain edema is crucial for managing patients who have suffered from a stroke. Brain edema, or swelling, occurs when there is an accumulation of fluid in the brain tissue, which can lead to increased intracranial pressure and further complications. In your aunt's case, it is concerning that her condition has deteriorated from being able to communicate to a state of unresponsiveness, despite the ongoing treatment.

1. CT Scans vs. Angiography: The decision to perform a cerebral angiography (a procedure that uses a contrast dye to visualize blood vessels in the brain) should be carefully considered, especially in elderly patients or those with pre-existing conditions such as heart issues. While angiography can provide valuable information about the location of the blockage, it does carry risks, particularly in patients who may have compromised health. The use of contrast agents can lead to allergic reactions or kidney issues, especially in patients with existing renal impairment. Given your aunt's age and heart condition, it is essential to discuss the risks and benefits of this procedure with her healthcare team. They can provide a more tailored assessment based on her overall health status and the potential for recovery.

2. Drainage Procedures: The option of placing a ventricular drain (a catheter that removes excess cerebrospinal fluid from the brain) is typically considered when there is significant hydrocephalus or when the brain edema is causing life-threatening pressure. However, this procedure also comes with risks, including infection and further complications. The decision to proceed with such an intervention should involve a multidisciplinary team, including neurologists, neurosurgeons, and geriatric specialists, who can evaluate whether the potential benefits outweigh the risks in your aunt's specific situation.

3. Current Treatment Options: High-pressure oxygen therapy can be beneficial in certain cases of stroke, particularly in reducing the size of the infarct and promoting healing. However, if your aunt's condition is worsening, it may indicate that additional interventions are necessary. Other treatment options may include medications to manage intracranial pressure, such as mannitol or hypertonic saline, and supportive care to ensure her comfort.

4. Palliative Care Considerations: Given your aunt's age and the severity of her condition, it may also be appropriate to consider palliative care options. This approach focuses on providing relief from symptoms and improving the quality of life, rather than aggressive curative treatments. Engaging with a palliative care team can help ensure that her needs and those of the family are met during this challenging time.

5. Communication with Healthcare Providers: It is vital to maintain open communication with the healthcare team. They can provide updates on her condition, explain the rationale behind the current treatment plan, and discuss any potential changes or additional interventions that may be appropriate.
In summary, while there are treatment options available for managing stroke-related brain edema, the decision-making process should be individualized, taking into account your aunt's overall health, the risks associated with potential interventions, and her family's wishes. Engaging with her healthcare team will provide the best pathway forward in navigating this difficult situation.

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