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My Mother In Law Has Recently Had Two Massive Strokes.
Question: My mother in law has recently had two massive strokes. I am hoping to get a better understanding of her current state based on the CT imaging I have from the hospital.
Ultimately - I would like to know if there is a chance of her coming out of her vegetative state, and if there is any medical precedence of someone recovering from the severity of her injury
Ultimately - I would like to know if there is a chance of her coming out of her vegetative state, and if there is any medical precedence of someone recovering from the severity of her injury
You can find her medical imaging at the following google folder.
https://drive.google.com/drive/folders/1Sv8-1zoK2HxHXpf1tkvnpT-tUQni4y5P?usp=sharing
https://drive.google.com/drive/folders/1Sv8-1zoK2HxHXpf1tkvnpT-tUQni4y5P?usp=sharing
Brief Answer:
Chances are very small.
Detailed Answer:
Hello and welcome to HealthcareMagic! I reviewed carefully the uploaded images, containing an MRI and CT from 28 July and a CT on 20 Sep.
I am afraid the situation looking in particular at the September CT is really grim. It seems there was an occlusion of both medial cerebral arteries, the arteries which supply the major part of the cerebral hemispheres. As a result there is extensive damage of both hemispheres and it's not surprising she is in a vegetative state.
Whether there is a chance of her coming out of the vegetative state, yes there is, but a small one. While it's not an exact science I would say there is less than 10% chance of that. Prognosis for vegetative state due to stroke is worse than that due to other types of brain injury.
The one thing in her favor would be her comparatively young age which is associated with a higher capacity of brain plasticity (the capacity of remaining brain cells of rewiring themselves, creating new connections to compensate for lost tissue). This plasticity process takes place during the first 6 months, after that period it is extremely unlikely, after 6 months it would be considered permanent vegetative state.
However as I said the damage is extensive, there is little tissue left to compensate for the lost one, so the chances of coming out of the current state are small. Even if she does, it is a matter of reaching minimally conscious state, she will be almost certainly severely disabled, bedridden and requiring constant assistance.
I am sorry that I couldn't provide more hope for you, I imagine you were hoping for more positive conclusions. I remain at your disposal for other questions.
Chances are very small.
Detailed Answer:
Hello and welcome to HealthcareMagic! I reviewed carefully the uploaded images, containing an MRI and CT from 28 July and a CT on 20 Sep.
I am afraid the situation looking in particular at the September CT is really grim. It seems there was an occlusion of both medial cerebral arteries, the arteries which supply the major part of the cerebral hemispheres. As a result there is extensive damage of both hemispheres and it's not surprising she is in a vegetative state.
Whether there is a chance of her coming out of the vegetative state, yes there is, but a small one. While it's not an exact science I would say there is less than 10% chance of that. Prognosis for vegetative state due to stroke is worse than that due to other types of brain injury.
The one thing in her favor would be her comparatively young age which is associated with a higher capacity of brain plasticity (the capacity of remaining brain cells of rewiring themselves, creating new connections to compensate for lost tissue). This plasticity process takes place during the first 6 months, after that period it is extremely unlikely, after 6 months it would be considered permanent vegetative state.
However as I said the damage is extensive, there is little tissue left to compensate for the lost one, so the chances of coming out of the current state are small. Even if she does, it is a matter of reaching minimally conscious state, she will be almost certainly severely disabled, bedridden and requiring constant assistance.
I am sorry that I couldn't provide more hope for you, I imagine you were hoping for more positive conclusions. I remain at your disposal for other questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I've got a few questions:
Is there any treatments we can do during the 6 month window that will give her a higher likelihood of any possible recovery?
How can we prevent future strokes(Besides just blood thinners)?
What is the likelihood that at any point in the future she will have the ability to communicate, knowing her current brain damage?
What percent of her brain would you assume is damaged?
What would you say is the absolute best possible recovery that could happen at this point, knowing her damage(think one in a million chances recovery)?
Is there any treatments we can do during the 6 month window that will give her a higher likelihood of any possible recovery?
How can we prevent future strokes(Besides just blood thinners)?
What is the likelihood that at any point in the future she will have the ability to communicate, knowing her current brain damage?
What percent of her brain would you assume is damaged?
What would you say is the absolute best possible recovery that could happen at this point, knowing her damage(think one in a million chances recovery)?
Brief Answer:
Read below
Detailed Answer:
Regarding the first question I am afraid that no treatment has shown any success. There have been many studies with different substances over the years like cerebrolysine, gliatiline, magnesium sulfate, ipidacrine etc. Unfortunately large scale studies have not shown any benefit, no medication which has given proof of significant improvement of the recovery process. Right now a medication called Nuraid II (not sure if available in the US) is being talked about and pushed by pharmaceutical companies, but up to now again there is no proven benefit in particular in severe cases such as this, is not included in any guideline.
Regarding prevention of future strokes addressing risk factors like high blood pressure and diabetes, giving blood thinners and statins remain the mainstay of therapy. The discussion to be made is which blood thinner should be given. The fact that there were stroke recurrences despite being on an antiaggregant like aspirin makes it necessary to consider anticoagulant medication like Warfarin. While more effective, because of risk of hemorrhagic side effects and need for monitoring it is usually indicated only in certain situation like when there is a clear heart source of stroke, but I would consider it in this case since Aspirin has failed.
In some rare scenarios, interventions in the heart or blood vessels are considered, but it would be impossible to recommend other interventions in this case in particular since the cause of the repeat strokes is not clear. Heart and carotid ultrasound haven't shown major abnormalities to justify these repeat strokes, neither has coagulation panel. I don't know if other tests like trans-esophageal heart ultrasound with bubble test, Angio CT or Angio MRI of the aortic arch, neck vessels and head with contrast administration, have been done at a later time, not mentioned in the reports. Those tests might elucidate something more regarding the source of the stroke. With the current info at hand in front of repeat strokes involving both sides I would put a heart source as the most likely origin.
The likelihood that she will be able to communicate is almost zero. The percentage of the cerebral cortex which is damaged is about two thirds. I am referring to the cortex of the hemispheres mind you, as it is the part dealing with cognitive functions, like language, memory, judgement, planning etc which makes us who we are.
The absolute best recovery (one in a million as you say) would be her waking up and being conscious of her surroundings, recognize familiar faces, following with the eyes, and being able to understand basic phrases (like open your eyes) and say some monosyllabic words like yes or no.
Read below
Detailed Answer:
Regarding the first question I am afraid that no treatment has shown any success. There have been many studies with different substances over the years like cerebrolysine, gliatiline, magnesium sulfate, ipidacrine etc. Unfortunately large scale studies have not shown any benefit, no medication which has given proof of significant improvement of the recovery process. Right now a medication called Nuraid II (not sure if available in the US) is being talked about and pushed by pharmaceutical companies, but up to now again there is no proven benefit in particular in severe cases such as this, is not included in any guideline.
Regarding prevention of future strokes addressing risk factors like high blood pressure and diabetes, giving blood thinners and statins remain the mainstay of therapy. The discussion to be made is which blood thinner should be given. The fact that there were stroke recurrences despite being on an antiaggregant like aspirin makes it necessary to consider anticoagulant medication like Warfarin. While more effective, because of risk of hemorrhagic side effects and need for monitoring it is usually indicated only in certain situation like when there is a clear heart source of stroke, but I would consider it in this case since Aspirin has failed.
In some rare scenarios, interventions in the heart or blood vessels are considered, but it would be impossible to recommend other interventions in this case in particular since the cause of the repeat strokes is not clear. Heart and carotid ultrasound haven't shown major abnormalities to justify these repeat strokes, neither has coagulation panel. I don't know if other tests like trans-esophageal heart ultrasound with bubble test, Angio CT or Angio MRI of the aortic arch, neck vessels and head with contrast administration, have been done at a later time, not mentioned in the reports. Those tests might elucidate something more regarding the source of the stroke. With the current info at hand in front of repeat strokes involving both sides I would put a heart source as the most likely origin.
The likelihood that she will be able to communicate is almost zero. The percentage of the cerebral cortex which is damaged is about two thirds. I am referring to the cortex of the hemispheres mind you, as it is the part dealing with cognitive functions, like language, memory, judgement, planning etc which makes us who we are.
The absolute best recovery (one in a million as you say) would be her waking up and being conscious of her surroundings, recognize familiar faces, following with the eyes, and being able to understand basic phrases (like open your eyes) and say some monosyllabic words like yes or no.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Last question - you've been fantastic. Thanks for your help!
Regarding the one in a million case of recovery - is there any medical precedence that you know of where someone has recovered from similar injuries to the state you refer to above?
Regarding the one in a million case of recovery - is there any medical precedence that you know of where someone has recovered from similar injuries to the state you refer to above?
Well, this question fits in with that last one. She currently has minimal response to stimuli - but does seem to show some. Minimal wincing to shots, etc.
Is it possible that in her current state she can perceive pain? Is it possible that she is aware in anyway of her state, pain, etc?
As you can imagine - we are concerned for helping her as best we can, but are fearsome that she is in a tortured state.
Is it possible that in her current state she can perceive pain? Is it possible that she is aware in anyway of her state, pain, etc?
As you can imagine - we are concerned for helping her as best we can, but are fearsome that she is in a tortured state.
Brief Answer:
Read below
Detailed Answer:
Hello again, sorry for answering a little late.
Regarding precedents, there are precedents of waking up after extensive damage, but usually it is in cases where the damage is due to traumatic brain injury not stroke. Traumatic brain injury has a better prognosis (in fact permanent vegetative state is considered after 12 months unlike stroke). Stroke has a worse prognosis. I don't remember reading about any similar case, but then these aren't cases which are usually published in medical journals. If I were to speak from personal experience there was a lady which I had as a patient 6-7 years ago with similar damage who seemed improved to the point of following with the eyes and seeming to recognize relatives, however until 4 months wasn't able to achieve any sort of communication or seeming to understand (I lost contact after that period). Apart from that case other similar patients have either remained in a vegetative state or succumbed to complications (mainly respiratory infections to which they are exposed due to their immobile state).
As for the pain issue, there are several links in the pain perception pathway. She certainly perceives something, the presence of a stimuli as the first links in the pathway are not affected. The question is whether the last step takes place, the interpretation of the stimuli as an unpleasant one, such as pain. This last step, the analysis of the stimuli and the attachment of an emotional significance takes place in the cortex of the brain which is damaged by the strokes. So this part of pain perception is certainly impaired. Whether completely or partially is hard to tell with patients not being able to communicate, there may be some perception of an unpleasant thing going on. However even in that case it should be a very vague perception, not the intense emotional experience which you fear I imagine.
Read below
Detailed Answer:
Hello again, sorry for answering a little late.
Regarding precedents, there are precedents of waking up after extensive damage, but usually it is in cases where the damage is due to traumatic brain injury not stroke. Traumatic brain injury has a better prognosis (in fact permanent vegetative state is considered after 12 months unlike stroke). Stroke has a worse prognosis. I don't remember reading about any similar case, but then these aren't cases which are usually published in medical journals. If I were to speak from personal experience there was a lady which I had as a patient 6-7 years ago with similar damage who seemed improved to the point of following with the eyes and seeming to recognize relatives, however until 4 months wasn't able to achieve any sort of communication or seeming to understand (I lost contact after that period). Apart from that case other similar patients have either remained in a vegetative state or succumbed to complications (mainly respiratory infections to which they are exposed due to their immobile state).
As for the pain issue, there are several links in the pain perception pathway. She certainly perceives something, the presence of a stimuli as the first links in the pathway are not affected. The question is whether the last step takes place, the interpretation of the stimuli as an unpleasant one, such as pain. This last step, the analysis of the stimuli and the attachment of an emotional significance takes place in the cortex of the brain which is damaged by the strokes. So this part of pain perception is certainly impaired. Whether completely or partially is hard to tell with patients not being able to communicate, there may be some perception of an unpleasant thing going on. However even in that case it should be a very vague perception, not the intense emotional experience which you fear I imagine.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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