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« HEY RUBE! WANNA TRY AT THIS? | Main | Grand Rounds. Period. »

Comments

Craig H

Unless someone can find evidence that Ms. Schiavo ever had a shunt placed, this is not her head CT. Also, this is one cut -- where's the rest of the CT? Elementary radiologic interpretation: make sure the name on the film matches the name of the patient.

Suspicious, but certainly willing to be informed,

CodeBlueBlogMD

There is no name on the CT (I assume) because HIPPA regulations forbid it.

They only provided me with one cut; however, when you have the type of experience I DO (I've seen 10,000 brain CT's) you can pretty well infer the rest of the study. Granted there could be OTHER surprises on the scan; however, I can judge the severity of GLOBAL ISCHEMIA-caused atrophy based on this cut, and I'm willing to BET on it.

You are correct about that shunt -- that is really remarkable. Why would they shunt her unless she had obstructive hydrocephalus -- and how did she GET THAT?!

Craig H

Karen Quinlan's pathology was disproportionately subcortical -- bithalamic ischemia -- with relative cortical sparing. That's why the other cuts matter, and why the functional severity of the hypoxic injury can't be inferred from this picture.

No matter though. Tere's no indication from any of the medical or legal timelines available (online anyway) that Ms. Schiavo ever had a shunt.

CodeBlueBlogMD

They specifically say, in all documents and releases, that it is Terri Schiav's CORTEXZ that was affected, which is the focus of the injury one would expect given the mechanism of cardiac dysrythmmia leading to global cerebral ischemia.

Selective thalamic ischemia is quite unusual. I don't remember Quinlan's etiology but selective thalamic ischemia is usually a poisoning -- such as carbon monoxide, I believe -- something that has not been adduced as a mechanism for Schiavo.

In any event, I am not saying that I do not want to see the entire CT -- I do! This is all they are providing us with; and if THIS is what they based this case on, they have made a HUGE error.

CodeBlueBlogMD

One more thing...part of the perception of Schiavo's atrophy is THE SIZE OF THE VENTRICLES! To the interpreter of a CT scan, hugely dilated ventricles in the setting of diffuse atrophy suggests hydrocephalus ex vacuo: enlarged ventricles due to the NEGATIVE pressure effect of atrophied cortex. And this observation WORSENS the severity of the cortical atrophy in the perception of the interpreter.

Patricia

I'm in neuropsych and am not qualified to read CT's, but even I can tell there's a problem with their reading if this is her CT.

It's been reported that she spoke a few words and walked some with parallel bars when she was in rehab, but I don't know if that report is accurate.

What to do???

DrTony

I heard an interview on the radio today with a physician who has over 10 hours evaluating Terri. He stated that she is not unconscious. He indicated that when he commented on the scene outside her hospital room window, she turned to look out the window. She vocalizes in an attempt to communicate. The discussion on the radio also discussed affadavits from nurses who swore that Mike refused treatment with antibiotics for UTI's, refused to allow evals by rehab physicians and refused imaging studies such as MRI and PET scans.

The physician being interviewed also stated that his opinion, based on a review of the medical records, is that Mr. Shiavo deliberately moved Terri from nursing home to nursing home whenever the staff would get suspicious about his refusal of care. One nurse quoted Mr. Shiavo as saying, "Let the bitch die."

NotADoctor

Are you sure that's a shunt? In the reports filed she had some electronic stimulation gadget implanted in her brain, at the request of her husband, not too long after her "accident".

Claire

I have seen a couple of references to a shunt and questions to why it had been allowed to remain in place this long.

Still looking for *where* I saw them...

Also references to full sepsis after a time with no antibiotics for a UTI. At that point a court stepped in and enforced the law that forbids a guardian to withhold basic medical care. There was a reference to the sepsis causing further brain damage, but I've no idea if that is possible. Is it?

Claire

I have seen a couple of references to a shunt and questions to why it had been allowed to remain in place this long.

Still looking for *where* I saw them...

Also references to full sepsis after a time with no antibiotics for a UTI. At that point a court stepped in and enforced the law that forbids a guardian to withhold basic medical care. There was a reference to the sepsis causing further brain damage, but I've no idea if that is possible. Is it?

NotADoctor

Found this little tidbit in a google search:

27. Judge Greer has allowed violation of 744.3215(b) not requiring Michael to have follow up examinations of electrodes, which were implanted in Terri’s brain. These implants should have been removed years ago, as they are a source for both infection and hydrocephalus. Hydrocephalus may cause pressure that could suppress cognitive function and be responsible for much of Terri’s condition. If so, there could be a vast improvement in her condition if a shunt were placed. Hydrocephalus could also cause pressure that would flatten the brain and show fluid filled areas on a brain scan.

http://libertytothecaptives.net/judge_greer_violations_statutes.html

I am not a physician, that's why I am asking all of you. Is that really a shunt on the CT or one of those implanted electrodes, and could the electrodes account for the amount of hydrocephalus found? Why are people asking for a shunt, if a shunt is already there? Wouldn't placement of such show up in the medical record or be noticed on subsequent physician examinations, and therefore noted?

Just asking.

caltechgirl

I too want to see the rest of the scan if it is indeed Terri's. Thanks for posting what I've been trying to point out, but have far less credibility to say (I've taught 1st year med students what to look for in CTs and done research with MRIs, but I don't do this for a living, being a lowly PhD student). I've seen a worse-looking scan of a conscious, talking person, but again, the differences were in other slices.... I'll look forward to whatever else you dig up.

CodeBlueBlogMD

That's a shunt tip, for sure.

First, if you implant an "electrode" the purpose is for the electrode to "stimulate" neural tissue for some effect. There is no neural tissue floating in the CSF inside that venticle. Implantable electrodes would need be superficial.

That is the tip of a venticulatr shunt which we are only seeing on one scan slice (because that's all we have). It was placed there to relieve increased intraventicular pressure which can have 2 causes: overproduction of CSF or obstruction to CSF outflow (= "communicating" and "noncommunicating" hydrocephalus).

Here is the important part: In a patient of her age, given her circumstances, this would almost surely be "noncommunicating" hydrocephalus, which is almost always caused, in this situation, by a "clot" at the level of the ventricular drainage (Foramen of Magendie; which is EXTRAAXIAL, meaning that the clot had its genesis OUTSIDE OF THE NEUROAXIS...to a specialist this means she had BLOOD IN HER CSF.

How do you get that?

From getting smashed on the head (as in an assault).

So how would she have got smashed on the head?

Why don't we know this?

Why can't I find refenerence to this shunt in her case?

Stop the presses, someone.

NotADoctor

Thank you very much for your answer. Is there a reason why hydrocephalus would be due more so to old injury than to the long-term effects of the electrode placement?

Just trying to get all my facts in a row....

CodeBlueBlogMD

There IS NO electrode.

This is a plastic tube (= a shunt) placed there to RELIEVE an obstruction.

THAT obstruction is the element in discussion: how did she get it?

Most comony THAT obstruction would be secondary to bleeding OUTSIDE of the brain tissue (= subarachnoid or subdural hemorrhage). How does one GET this get of hemorrhage?

FROM TRAUMA. LIKE A SMASH ON THE HEAD.

NotADoctor

I'm sorry, I didn't make myself clear. I know what a shunt is, I'm speaking of the electrodes that were implanted in her brain in 1992, which have never been removed, and to which some would explain the resulting hydrocephalus on the CT in 1996.

**Ms. Schiavo could be evaluted with a PET scan in her current condition. However, an MRI cannot be done without first removing experimental electrodes which were implanted within her brain in 1992. The doctor who implanted them instructed Mr. Schiavo to have them removed, but that has not been done.[13]

(http://www.nationalreview.com/script/printpage.asp?ref=/comment/johansen200503160848.asp)**

http://en.wikipedia.org/wiki/Terri_Schiavo



Mark

These comments are intriguing. I've linked to them on my blog.

CodeBlueBlogMD

I don't see any signs of electrodes on this slice of the CT.

Also, I know of no electrodes that anyone would leave in any brain for any purpose, and in 20 years of seeing more than 10,000 CT's of the brain, I have never observed such a phenomenon.

In addition, it is hard to believe that anyone inserted electrodes, in 1992, that had paramagnetic properties that would preclude an MRI of the brain currently. I doubt that. Most of those devices are titanium or stainless steel, which are unaffected by MRI. Besides, with MRI, in that type of situation, the only reason not to do an MRI is because you are looking for information in the region of the artifact, where there would be distortion of the image.

If the items are not paramagnetic (like iron), there would be no danger and no contraindication to an MRI. Sounds bogus to me.

Finally, yes, if someone penetrated the dural linings of her brain with electrodes, that procedure could possibly (but not likely) have created a hemorrhage that resulted in hydrocephalus. But I have a long way to go before I believe that.

NotADoctor

According to Michael Schiavo's November 19, 1993 deposition, case No. 90-2908-GD, the electrodes implanted were platinum.

NotADoctor

The experimental procedure was performed by Dr. Yoshio Hosobuchi of the University of California at San Francisco.

NotADoctor

Hosobuchi Y, Yingling C.
The treatment of prolonged coma with neurostimulation.
Adv Neurol. 1993;63:247-51. No abstract available.
PMID: 8279309 [PubMed - indexed for MEDLINE]

Ed Jordan

CodeBlue,

If you want to contact someone close to the Schindlers to share your discoveries, one person to contact is Rev. Robert Johansen of the Thrown Back blog. Fr. Johansen is a friend of the Schindler family, and he has been gathering the names of physicians who think Terri can recover. I think he would be interested in hearing from you.

http://www.thrownback.blogspot.com/

frrob@earthlink.net

Michael Ditto

Have you ever treated a heart attack patient? To suggest that the only way someone could get blood in the CSF is being "smashed on the head (as in an assault)" is curious. Would you care to back that up with some data? Are you saying that there is no such thing as heparin-induced thrombocytopenia?

Michael, he's basing his assesment on "20 years of seeing more than 10,000 CT's of the brain". I think he's perfectly qualified to form an opinion without having to quantify it with data.

Anyway, this whole thread is misleading. You can't judge a patients neurological health TODAY based on a CT from 1996.

The fact that there is no CT from 2005 is what is really disturbing. Also the fact that there has been no INDEPENDENT review of Ms. Schiavo's current neurological condition.

The fact that there was hydrocephalus in 1996 just proves the neglect on the part of the Guardian of Ms. Schiavo. That alone should be enough to require a review of her treatment and an independent investigation into factual nature of her disability.

Right now all we have are arguments from two parties that are equally biased. Why won't Michael Schiavo let DCF perform their own investigation as they have petitioned the court to do?

Curious JD

Would you allow someone you did not know whose motives are directly adverse to what you believe your spouse wanted just because they petitioned the court?

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