Brain Stem Stroke

[Poorvisha]

As my father is affected by Acute Brain Stem Infarct (Pontine Stem Stroke) which has all the vital functions like breathing, swallowing, sleeping, thinking, movements etc. He got the stroke on 2nd Mar 2012 and now he is able to breath by himself. Swallowing is not properly done, so Ryle's tube is inserted through the nose for his feed. He is not able to move and he is bed - ridden.

On 26th Mar 2013 he vomited some black particles through the Treacheostomy tube. When we took him to hospital, we came to know he is affected with "Paralytic Ileus", that is gas is inside his stomach and he is not able to urinate and stool. He was admitted on 26th Mar 2013 at Neuro Foundation, Salem and then discharged on 31st Mar 2013. But again on 31st Mar 2013 night, he vomited from his mouth and all the feed which we have given from the Ryle's tube came out. And his stomach was hardened and on 1st April 2013 morning, Nurse inserted Folis Cathetor for urination and made the Ryle's tube to aspirate to make all the undigested food to come out from the stomach. Late Evening, RL (Saline) was given and on 2nd April 2013 again his stomach became slightly hardened and Ryle's tube came out from the stomach to the mouth which must not happen.

And his GCS(Glasgow Coma Scale) was E2VTM2 ( E- Eye, V- Verbal, M- Motor Response) and now it is improved to E4VTM4. Now he is able to swallow atleast 20 spoons of liquid, he can understand everything about what we are speaking. He will smile, cry. He will also look at us if we ask him to do. Suddenly his Ryle's tube came to his mouth twice on 2nd April 2013 and 4th April 2013. Hoping because of reflex. Physiotherapist said that he is in need of some Positive energy to get recovered. Sometimes, he also keeps his hand on his lap. Sometimes, on his stomach while giving physio. Can you please tell me how can I help my dad to get recover from this and also why the Ryle's tube came out to his mouth.

[Poorvisha]

Thank you so much for a kind reply.

He is understanding very well whatever we are speaking. Sometimes he will smile and many times he will cry.

And also he is keeping his hands on his lap himself and also while giving Physiotherapy he is taking his hands till Stomach.

Can you please tell whether this is a sign of Motor Response. Localises Pain?

Regards,
Poorvisha

[S. Kaul, MD]

Hi there!

Well, without knowing the relevant clinical details or a detailed clinical evaluation it would be difficult to comment specifically on the situation. Management in chronic strokes is largely rehabilitative/ supportive and neurological improvement is unlikely beyond 6-12 months of stroke. It would be difficult to comment on the cause of the displacement of the ryle’s tube. Possible causes include, reflux, increased stomach pressure, neuromuscular causes etc. Ryle’s tube displacement is not an issue with a tracheostomy since there is little risk of aspiration and the tube can be replaced easily. I would suggest discussing the situation and the suggested management plan in detail with his treating doctor(s).
Hope this is helpful.

Take care!