Elizabeth Smart Case - Ricci Dies in Hospital

More likely there will be a quick cremation.

As far as Angela Ricci is concerned, she's an ex-con and not to be trusted.

There are an awful lot of people in this world who are NOT ex-cons and cannot be trusted.

True. But by her history, lifestyle, and company she keeps, I would be far less trustful of her.

There is usually an autospy before cremation. I'm hopeful one will be done in this case as well.

No one killed Ricci; he brought death upon himself through his lifestyle of drinking, drug use etc.

You really need to temper those remarks. My mother suffered from the exact type of stroke that felled Ricci and I can guarantee you she did NOT have a "lifestyle of drinking, drug use, etc."

http://www.medschool.lsumc.edu/Nsurgery/spontICH.html

Spontaneous Intracerebral Hemorrhage

Deepak Awasthi, MD

Department of Neurosurgery; Louisiana State University Health Sciences Center- New Orleans

Introduction:
Intracerebral hemorrhage (ICH) is more than twice as common as subarachnoid hemorrhage (SAH) is much more likely to result in death or major disability than cerebral infarction or death. (1) Despite this impact, only a few studies have addressed the management of this problem. In these small randomized studies, neither surgical nor medical treatment has been shown conclusively to benefit patients with ICH.
Advancing age and hypertension are the most important risk factors for ICH. (1, 10) ICH occurs slightly more frequently among men than women and is significantly more common among young and middle-aged blacks than whites of similar ages. (1)
Incidence rates of ICH among Asian populations are also higher than those reported for whites in the US and Eurpoe. Pathophysiological change in small arteries and arterioles due to sustained hypertension is generally regarded as the most important cause of ICH. (1) Cerebral amyloid angiopathy is increasingly recognized as a cause of lobar ICH in the elderly. (1,10) Other causes if ICH include vascular malformations, ruptured aneurysms, coagulation disorders, use of anticoagulants and thrombolytic agents, hemorrhage into a cerebral infarct or brain tumor, and drug abuse. (1)
Of the estimated 37, 000 Americans who experienced an ICH in 1997, 35% to 52% were dead at 1 month; half of the deaths occurred within the first 2 days. (1) Only 10% of patients were living independently at 1 month; 20% were independent at 6 months. (1)

Diagnosis of ICH and Its Causes:
The classic presentation of ICH is sudden onset of a focal neurological deficit that progresses over minutes to hours with accompanying headache, nausea, vomiting, decreased level of consciousness, and elevated blood pressure. The early progression of neurological deficit in many patients with an ICH is frequently due to ongoing bleeding and enlargement of the hematoma during the first few hours. Patients with ICH uncommonly present with symptoms on awakening from sleep (about 15%). (1) An early decrease in level of consciousness is seen in about 50% of patients with ICH, an uncommon early finding in patients with ischemic stroke. (1) Headache occurs in about 40% of patients with ICH, compared with about 17% with ischemic stroke. Vomiting is an important diagnostic sign, especially if the hematoma lies within the cerebral hemisphere. It is important to remember that vomiting is common in patients with a stroke of any type in the posterior fossa. Elevation in blood pressure, often to very high levels, occurs in as many as 90% of patients with ICH. (1) Seizures occur in only about 6-7% of patients with ICH but are more common with lobar than deep hemorrhages. It is important to get a good general medical history in patients with, including history of trauma. One should try to elicit factors tha may predispose to ICH, such as hypertension, use of anticoagulants or thrombolytics, use of illicit drugs, heavy use of alcohol, or hematologic disorders.
Computed tomography (CT) is the key initial diagnostic evaluation. It clearly differentiates hemorrhagic from ischemic stroke. It also demonstrates the size and location of the hemorrhage and may reveal structural abnormalities such as aneurysms, arteriovenous malformations, and brain tumors that caused the ICH as well as structural complications such as herniation, intraventricular hemorrhage, or hydrocephalus.
The likely cause of the ICH can, at times, be determined by the location of the ICH as seen on the CT scan, the presence of structural abnormalities as seen on brain imaging, associated medical conditions such as hypertension, and the patientís age. Hemorrhages that originate in the putamen, globus pallidum, thalamus, internal capsule, deep perventricular white matter, pons, and cerebellum, especially in a patient with known hypertension, are often attributed to hypertensive small-vessel disease. In contrast, lobar hemorrhages are often thought to be due to amyloid angiopathy or other mass lesions (AVM, tumor).

Role of Angiography in ICH:
CT findings that prompt the impression of a structural lesion are the presence of subarachnoid or intraventricular hemorrhage, abnormal intracranial calcification, prominent vascular structures or the site of the hemorrhage (eg, perisylvian hemorrhage). In patients with these CT findings, angiography yielded a vascular etiology in 84% of the patients with ICH. A prospective study of angiography in patients with ICH by Zhu et al indicated that cerebral angiography has a low yield in identifying an underlying vascular abnormality in patients > 45 years old with a history of hypertension and a thalamic, putaminal, or posterior fossa ICH. (11) Thus, angiography should be considered for all patients without a clear cause of hemorrhage who are surgical candidates, especially young, normotensive patients who are clinically stable. In general, angiography is not required for older hypertensive patients who have a hemorrhage in the basal ganglia, thalamus, cerebellum, or brain stem and in whom CT findings do not suggest a structural lesion. Most older patients with deep hemorrhages die or have severe morbidity related to the hemorrhage and are not candidates for angiography. Timing of the angiogram depends on the patientís clinical state and the neurosurgeonís judgment concerning the urgency of the surgery, if needed.
MRI and MRA are helpful and may obviate the need for cerebral angiography in selected patients. They should be considered to look for cavernous malformations in normotensive patients with lobar hemorrhages and normal angiographic results who are surgical candidates.

Initial Management of Acute ICH:
Initial mangement is directed toward basics of airway, breathing and circulation, and detection of focal neurological deficits. Attention should be given to detecting signs of external trauma. Although intubation is not required for all patients, airway protection and adequate ventilation are critical. Patients who exhibit a decreasing level of consciousness or signs of brain stem dysfunction are candidates for aggressive airway management.

Medical Management in the ICU:
Medical management is geared towards blood pressure and intracranial pressure (ICP) control.
Blood Pressure Management:
The optimal level of a patient's blood pressure should be based on individual factors such as chronic hypertension, elevated ICP, age, presumed cause of the hemorrhage, and interval since onset. In general, recommendations for treatment of elevated blood pressure in patients with ICH is more aggressive than those for patients with ischemic stroke. It is recommended that blood pressure levels be maintained below a mean arterial pressure of 130 mm Hg in patients with a history of hypertension. (1) In patients with elevated ICP who have an ICP monitor, cerebral perfusion pressure (CPP=MAP-ICP) should be kept >70 mm Hg. Mean arterial pressure >110 mmHg should be avoided in the immediate postoperative period. If systolic pressure falls below 90 mm Hg, pressors should be given.
Increased ICP Management:
ICP control is essential, as it intracranial hypertension is a major contributor of mortality after ICH. ICP may be managed through osmotherapy, controlled hyperventilation, and barbiturate coma. Elevated ICP is defined as ICP > 20 mm Hg for > 5 minutes. The therapeutic goal for all treatment of elevated ICP is ICP < 20 mm Hg and CPP > 70 mm Hg. Patients with suspected elevated ICP and deteriorating level of consciousness are candidates for ICP monitoring. In addition to the mass effect of the hematoma, secondary hydrocephalus may contribute to elevated ICP. Ventricular drains should be used in patients with or at risk for hydrocephalus.
Other Medical Management Issues:
The goal of fluid management is euvolemia. In patients with ICH, prophylactic antiepileptic therapy (preferably phenytoin) may be considered for 1 month and then tapered and discontinued if no seizure activity occurs during treatment, although data supporting this therapy are lacking. Body temperature should be maintained at normal levels. Many patients who are delirious or stuporous are agitated. In these patients, short-acting benzodiazepines or propofol are preferred. Depending on the patientís clinical state, physical therapy, speech therapy, and occupational therapy should be initiated as soon as possible.

Surgical Treatment of ICH:
The ideal goals of surgical treatment of ICH should be to remove as much blood clot as possible as quickly as possible with the least amount of brain trauma from surgery itself. If possible, surgery should also remove the underlying cause of ICH, such as an AVM, and prevent complications of ICH such as hydrocephalus and mass effect of the blood clot. Craniotomy has been the standard approach for removal of ICH. Its major advantage is adequate exposure to remove the clot. Technical advances in removal of ICH include improved localization of the hemorrhage by stereotactic devices or intraoperative ultrasound. (1,4) Randomized studies comparing surgical v. medical management of ICH are few. (2,5) These, along with non-randomized studies, have led to recommendations for surgical treatment of ICH. (1,3,6,7,8,9)
Guidelines for Surgical Removal of ICH:
Non-surgical candidates:
patients with small hemorrhages (<10cc) or minimal neurological deficits
patients with GCS < 4; exception: cerebellar hemorrhage with brain stem compression- these patients may still be candidates for lifesaving surgery in certain clinical situations
Surgical candidates:
patients with cerebellar hemorrhage > 3cm who are neurological deteriorating or who have brain stem compression and hydrocephalus from ventricular obstruction.
ICH associated with structural lesion such as an aneurysm, AVM, or cavernous malformation may be removed if the patient has a chance for a good outcome and the structural lesion is surgically accessible.
young patients with a moderate to large lobar hemorrhage who are clinically deteriorating; size of lobar hemorrhage > 3cm; midline shift > 3mm; age < 65

There are an awful lot of people in this world who are NOT ex-cons and cannot be trusted.

Takes one to know one ;^0

A conspiracist might say something like the accomplice was a Middle Easterner who kidnapped Elizabeth for someone high in the Saudi government, say. Because of the 'sensitive nature' of such a situation to keep Ricci quiet they might set up an FBI 'medical' team at the hospital and fly Ricci there for an 'operation' by them. No reporters are allowed in, Ricci quickly has the plug pulled when in actuality he is disguised and taken to the airport to fly to South America where Angela will meet up with him in a few months. A quick cremation would be the next logical step.

factors tha may predispose to ICH

"predispose" being the key word here, which does not mean "cause."

I thought the family decided to withdraw life support...after necessary tests were completed to determine brain activity.

When you get right down to it, it's really very sad.

I pray the Ricci family will find peace in their loss...and I pray the Smart family will find answers even though Ricci is deceased.

Takes one to know one ;^0

Really? That should make life easier for you.

Would you care to borrow some tin foil? :o)

Thank you for sharing your story with us. You did the right thing in what has to be the hardest of all life's difficult situations.

Actually, it's quite possible this brain stem hemorrhage was indeed spontaneous. A spontaneous brain stem bleed is rare but does occur and includes not only horrible headaches, but deep breathing (pontine breathing). I doubt this bleed was caused by external blows. The sort of brain bleed caused by being beaten would be most likely under the skull, not at the base of it.
Just my .02,

whenigettime

How does a brain stem bleed differ from subdural hematoma? You sound like you know what you're talking about...could a bleed of Ricci's type be caused by past drug/alcohol abuse?

Fox News excerpt: He had not been listed as brain dead because he could still breathe on his own, although he was on a ventilator, Dr. Richard J. Sperry said.
Earlier Friday, Dr. Elaine Skalabrin, University of Utah Hospital's director of the Neuro Critical Care Unit, said Ricci had been extremely unlikely to recover. Most of the damage to Ricci's brain occurred before he arrived at the hospital, she said.

Ricci's family, including his wife, Angela, his mother, a brother and sister, decided to take Ricci off life support.

I hope the state didn't press the family to act quickly. If Ricci lived, but was vegetative, the state would have to pick up the costs because he would still be a prisoner. That could mean years. Sometimes in grief, people do things they would ordinarily think more about first.

I just got off the phone talking to my mom. I am not home, I am on a business trip. Anyway, Angela Ricci and Ricci's family decided to have the life support disconnected, because Ricci had irreversible damage done to his brain stem. Angela Ricci read a statement saying how kind Richard Ricci was to her and her son. And then the report said that Angela Ricci is grieving heavily.

The Smarts are offering two different rewards today. One: they want to know who picked up Richard Ricci after he dropped his Jeep Cherokee back at Roul's auto repair store. Two: They also asked for information regarding a July 24 attempted break-in at the Cottonwood Heights home of Jeannie and Steve Wright. Lois Smart, Elizabeth's mother, is Jeannie Wright's sister. Initial reports that the break-in was just a prank have never been proved.

My mom also said that the reporter said that Ricci would never answer who picked him up that day from the auto repair shop...

I found this information in the article just below the one you just quoted.

Meanwhile, Ricci's condition remained critical. Prison officials are starting to face the hard question of what to do if Ricci lives but never wakes up.

"The family is looking at that possibility, frankly," prison spokesman Jack Ford said Thursday afternoon.

Ford said that in the event Ricci lived and his family declined to take him off life support, he still would be considered a prisoner but would have to remain at the hospital at state expense.

Ford said that if Ricci remained persistently vegetative, the Board of Pardons likely would release him.

"The only thing the board's going to be considering is public safety, and if he's incapacitated, he's no further threat," Ford said.

Nancy Pomeroy, the Ricci family spokeswoman, said Ricci was responding to pinpricks by pulling away, but that was all.

Ricci had a history of hypertension, but was not on medication while in the prison, Ford said.