Terri Schiavo R.I.P. Part III: The Brain Speaks

Terri Schiavo R.I.P.

The CodeBlueBlog Papers

Part III

This is a summation in three parts.

Part I is here.

Part II is here.

The Third Revelation

After looking at the medical records of TS late in the game (the feeding tube was to be withdrawn any day), last month, I was emailed a link at the The EmpireJournal that gave a chronology of TS's hospitalization, purportedly written by caregivers on the scene. Three CT scans of the brain were listed thus:

2/25: Normal

2/27: Normal

3/30:  noncommunicating hydrocephalus, changes occurred since 2/27 exam

One must remember that a cornerstone of the "dead cortex/dead brain" rhetoric was that there had occurred, before hospital admission, a massive event of hypoxia-anoxia. What does this mean?

Hypoxia means low oxygen concentration (in this case to the brain) and anoxia means no oxygen. The mechanism finally settled on that was blamed for the hypoxia/anoxia was dysrythmmia/arrhythmia of the heart (ineffective heart pumping due to "electrical" disturbance) secondary to potassium deficiency brought on by diet change.

Translated, this means that TS had severe dietary changes that lead to a decrease in blood potassium that disrupted the normal electrical activity that stimulates the heart to beat (contract and relax). The heart thus contracted abnormally, leading to severe decreased blood flow to the brain and resulting in oxygen deprivation. This lack of blood flow/oxygen severely injured the cerebral cortex.

There are plenty of medical arguments and issues that can be raised regarding the above paragraph and the proposed scenario. None of that is important in my analysis. I am starting from the assumption -- now taken as fact -- that TS suffered severe oxygen deprivation to the brain causing massive anoxic (oxygen deprivation) damage to the cortex before she ever reached the emergency room.

Brain cortex is extremely sensitive to oxygen levels in the blood, and certainly, when there is prolonged oxygen deprivation, widespread cortical injury and  destruction can occur. The experts who repeatedly showed TS's CT brain slice in the media were supporting a direct chain of events from:

irregular heart beat ---> oxygen deprivation ---> cortical injury ---> massive atrophy

In order to manifest that degree of cortical atrophy from the single assumed event of hypoxia/anoxia, before admission, the degree of cortical damage, at the time of oxygen deprivation, must have been great.

So how was the CT scan at 48 hours negative?

Mechanisms of Madness

Severe hypoxia/anoxia leads to rapid injury of the cells in the brain's cortex. When the cells are severely damaged, they leak fluid. This fluid rapidly accumulates in the closed space of the skull.

Damage to the brain, from oxygen loss, has been shown to occur within twenty minutes, and in severe cases, begins to show on CT scans within hours. In a case such as TS, where there is proposed massive damage, one would expect massive reaction to the damage. After 24 hours there usually is substantial brain swelling in a case such as this, evident on the CT scan.

My experience with the handful of cases I've seen is that the CT evidence of massive hypoxia/anoxia (of the extent being proposed by the experts who point to TS's CT) is evident soon after the event. By 24 hours, I'd be surprised not to see some evidence; and, if I did not see swelling and abnormalities by 48 hours after the event, I would be perplexed enough to seek alternative explanations or a reevaluation of the case.

Most research concerning massive hypoxia and anoxia is in newborns, and, obviously, a newborn brain is different from an adult brain. Nonetheless, here's a report from one study:

Hypoxic-ischemic insults to the central nervous system of infants may show a characteristic sequence of imaging findings. CT immediately after the insult may be normal or near normal in appearance. Over 24-48 hours, diffuse cerebral edema causes loss of the distinction between grey and white matter, obliteration of cortical sulci, and diffuse low density

Here's a case, reported in the Japanese literature of a woman who suffered massive cerebral anoxia/hypoxia and had immediate follow-up CT (after resuscitation). According to the authors:

CT revealed massive cerebral edema soon after resuscitation ...

And a repeat CT the next day showed:

on the following day (after anoxia/hypoxia) the CT demonstrated low attenuation area of white matter and gray matter in the cerebrum and brainstem

By 48 hours it is hard to imagine that the CT scan would not show some evidence of swelling and/or changes in the relative appearance of different parts of the brain.

The cases of massive hypoxia/anoxia I have seen, have been in adults, and have been grossly, markedly abnormal by 24-48 hours. The swelling can be so bad that a neurosurgeon has to remove a part of the skull so that the brain has an outlet to bulge.

Some have written me to explain that the CT used may have been an old model and not been as sensitive as newer models; however, as early as 1983 The American Journal of Radiology (AJR Am J Roentgenol. 1983 Dec;141(6):1227-32), reporting on a study of adults said:

Even with no clinical information, neuroradiologists can assess CT signs of cerebral infarction within the first 6 hours of symptom onset with moderate to substantial interobserver agreement.

I was incredulous to read that TS's CT was interpreted as "normal" 48 hours after the proposed event of hypoxia/anoxia. Surely, given the amount of damage being proposed in the media -- with that famous CT slice -- there would be some sign of the brain's distress at 48 hours. But the CT report produced on The Empire Journal said that the 48 hour CT was "normal." And a CT report from a scan done one month later (3/30) reported "noncommunicating hydrocephalus, changes occurred since 2/27 exam." This report was given by a different radiologist than the report of 2/27, indicating that this different radiologist re-evaluated the CT of 2/27 to compare it with 3/30, so the CT of 2/27 was seen twice, by two experts.

Pictures at an Exhibition

Here are some CT images of brains -- taken at 24 hours -- that suffered massive hypoxia/anoxia:

                     

**************

                   **************

                   **************

***********

***************

***************

****************

*************

****************

****************

****************

**************

These brains show diffuse swelling, with loss of the normal spaces between cortical folds, and abnormally different shades of "grayness" that are immediately evident to an interpreter. According to a prominent University's teaching file, here are the CT findings of massive cerebral hypoxia/anoxia after 24 hours:

CT immediately after the insult may be normal or near normal in appearance. Over 24-48 hours, diffuse cerebral edema causes loss of the distinction between grey and white matter, obliteration of cortical sulci, and diffuse low density. Frequently there is relative sparing of the cerebellum and or basal ganglia which appear hyperdense compared to the abnormally low density cerebral hemispheres.

Mirrored Spectacles

How could this be?

Here are the possibilities:

• I think that the least likely explanation is that the CT actually was negative.
• The CT may have been misinterpreted. Sometimes when there is uniform, massive abnormality -- and all things in the brain are equally abnormal -- there can be the phenomenon when the interpreter sees everything in a uniform state and calls it negative. This happens, and it is not necessarily malpractice or incompetence. Interpreting CT's is just that: interpreting. I look at a Rorschach image and call it a butterfly, you call it a wildebeest. However, given the history of a massive event of anoxia/ hypoxia, one is usually on the alert for the appropriate changes.

• The CT scanner may have been an old model that was less sensitive than newer models available at that time. Not everyone upgrades their equipment every time a new generation of equipment is available, same way you don't upgrade your computer every time there is a new memory chip. Older CT's in 1990, could produce pretty poor images, at times, and if you throw in a little motion artifact (patient moving her head, etc), the combination of these two factors might lead to misinterpretation.

• The CT was actually negative, or normal. If the CT was actually normal, it is hard to postulate massive hypoxic injury two days prior. So if the brain was really negative, then the inciting event (massive hypoxia/anoxia) did not occur before TS was admitted to the hospital, it occurred after she arrived at the ER on 2/25/90 occurred after that time.

My impression that this discrepancy needed -- at the very least -- to be reevaluated by a second look at those CT scans before the removal of TS's feeding tube, lead to my attempts to draw attention to my observations.

Once again, my only contention when I reported this finding was that it needs to be explained. That's all. Like the bone scan, it is difficult for me to understand how results like these could be left alone and not commented upon. This was the crux of my issue. If one does not explain why the bone scan was abnormal or why the CT scans did not fit the clinical history, then by everything I know and have learned, one is obligated to investigate and pursue.

Comments

Who exactly started the information that Terri Schiavo was bulimic?

Was it a credible source - a doctor she was seeing or was it Michael Schiavo?

That has been around so long, I can't seem to find who
offered up that tidbit.

Thanks.

[med student]

I heard bulimia metioned on TV or read about it in mainstream media somewhere, but I don't know the original source of it.

[zheka]

n@mdjd

what would papilledema indicate if present at the time of the 2nd CT?

thank you

[retired doc]

There is a well known hospital in Los Angeles advertising to the general public with the following theme. Do you want your brain scan interpreted by a general radiologist or by a highly specialized neuroradiologist.

[retired doc]

For more on the development of the bulimia hypothesis, go to http://www.zimp.org/stuff/ and scroll down on the left to item 29, the Humana Northside Hospital discharge summary.

[Susan Nunes]

Terri might have been bulimic, but I seriously doubt she had osteoporosis and thus had bone fractures, given her age.

Like I've said, Michael Schiavo's claims were totally bogus from the time he got the money, and possibly before, and nothing he claimed EVER added up.

The medical "evidence" is like the Bible: you can prove "anything." Michael's actions prove he is a liar.

Face it: Terri was an inconvenience, and Michael was ready to move on with a new girlfriend and a hefty bank account and was willing to spend large chunks of money getting her killed off. Luckily for him but not for Terri, he found an idiot judge who didn't care about any evidence to the contrary and an opportunistic lawyer who was willing to carry out his wishes.

Nobody can argue differently and sound convincing. There are more holes in Schiavo's story than a slab of Swiss cheese, and those who support Michael Schiavo do it because it has to do with scoring political points against the likes of Jeb Bush and Tom DeLay.

Those riding on any medical evidence are going to be disappointed. That's why I look at the "loving husband's" ACTIONS, which are totally incriminating.

But this story isn't unique. Disabled people are killed off every day by "loving" relatives who find them too much of a burden.

The only thing making this case unique is the long time it took in the court system.

I do find it funny in a sadistic way that although Michael wanted his wife dead to collect on her trust account, allegedly almost all of the money is gone.

Serves him right.

[CodeBlueBlogMD]

You know, I can neither explain this further or better. If you do not understand what blogging is about, so be it.

I stand by what I've said.

[retired doc]

That is to say that you stand by your multiple errors. That blogging is about doing harm to people and never apologizing for mistakes. That one purpose of blogging is to promotes junk science. That you do not accept the Feynman dictum that the first duty of the true scientist is to prove himself wrong.

[zheka]

Susan

MS stands to gain much more than a few thousand dollars from TS trust fund. He is about to become a millionaire. watch out for book, movie or TV show based on the story. I am sure that something along the lines is in the works already

[ddb]

CBB -

Do you recall who or what were the first sources of
the information that Terri Schiavo was bulimic?

Was it a doctor who was treating her who had had her admit she was bulimic and her way of being bulimic - ?starving ?purging?

Or was it Michael Schiavo?

Thanks.

[AlohaRN]

re evidence of bulimia-
per the discharge summary from humana hospital -terri had a very low potassium level on admission, as well as low serum albumin and total protein levels, suggestive of some amount of malnutrition, along with her intake of 10-15 glasses of iced tea per day. also, eating disorders often result in irregular menses or absence of menses (amenorrhea), and terri was seeing an ob for fertility issues. the lawsuit was brought against the ob for falining to perform a complete workup (patient history and lab tests) that could have detected an eating disorder (possibly bulimia).

[AlohaRN]

to susan nunes - you wrote "Terri might have been bulimic, but I seriously doubt she had osteoporosis and thus had bone fractures, given her age."

did you do any research before you posted this?
a simple google search using bulimia, osteoporosis and osteopenia would be enlightening.

(as would a google search using cpr, fracture and ribs)

[n@mdjd]

CBB

You now say,

"You know, I can neither explain this further or better. If you do not understand what blogging is about, so be it.

I stand by what I've said."

You previously suggested that the widely shown CT slice showed the tip of a hydrocephalus shunt in a lateral ventricle. ("That  shining object is the tip of a shunt.") Do you still believe this, or do you now agree that the linear structure seen within the ventricle on the CT slice, and causing beam hardening, is most likely the DBS electrode passing though the ventricle?

You previously questioned whether the CT slice was that of TS ("IS THIS REALLY TERRI'S CT?") based on the purported presence of an unexplained shunt. Do you now agree that the CT slice is most likely that of TS, and that it demonstrates ventriculomegaly and cortical atrophy rather than hydrocephalus?

You previously stated that "There is categorically and absolutely NO WAY Terri could have suffered MASSIVE ANOXIC INJURY TO THE BRAIN ON 2/25 AND HAVE NORMAL CT SCAN ON 2/27." Do you still believe this despite the findings to the contrary of Morimoto et. al. discussed in my earlier posts? (Acute brain swelling after out-of-hospital cardiac arrest: pathogenesis and outcome. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=8420715&dopt=Abstract)

You have explained that radiologist interpretations of imaging studies are subject to error. Do you agree that the CT report of 3/30/90 by Dr. Abramson (summarized as "CT Scan shows noncommunicating hydrocephalus, changes occurred since 2/27 exam") is indicative of an observation of interval enlargement of the ventricles, but that radiologists have been known to incorrectly use the term "hydrocephalus" as a synonym for ventriculomegaly so that the cause of the enlarged ventricles cannot be determined from this fragmentary report?

Do you agree that the failure of TS's treating physicians to shunt her back in 1990 suggests that they did not agree with a radiologic diagnosis of obstructive, noncommunicating hydrocephalus? (Of course, if the diagnosis had been correct then the failure to shunt would have been the real malpractice case.)

Based on your belief that a "normal" brain CT would have been impossible 2 days after a severe anoxic episode, and relying on the reported finding of interval development of noncommunicating hydrocephalus, you postulated an interval intraventricular bleed (although there is nothing in the record to suggest this and no blood observed on the CT) and concluded, "So Terri WAS HIT ON THE HEAD OR DROPPED ON HER HEAD DURING LATER FEBRUARY OR EARLY MARCH WHILE IN THAT HOSPITAL." Do you still believe this conclusion, which was picked up and cited elsewhere, to be true?

As a radiologist with extensive experience in cross-sectional imaging you must understand that a linear foreign body projecting obliquely within an anatomic structure in a single slice (e.g. a shunt or electrode in a cerebral ventricle, a biliary drain in the common duct, a catheter in a cardiac chamber) may either be terminating within the slice or traversing the slice, and that without reviewing adjacent slices one cannot in general determine where the tip of the foreign structure is located. Nonetheless, you concluded that you were seeing "the tip" of a shunt. Why do you think you made this error? Was this a case of passion overcoming intellect?

Your discussion of the Shiavo CT has provoked a lively discussion on your blog and elsewhere, but unfortunately even the limited caveats you placed around your wilder speculations were dropped from summaries that cited your speculations and relied on your medical expertise to support serious allegations of wrongdoing. What level of responsibility do you think attaches to a medical blogger who posts as an expert?

[med student]

zheka-
Papilledema is a finding that one would make in an examination of the interior of the eye. In the back of the eye there is a region called the optic disc, which is where the optic nerve leaves the eye and the blood vessels enter/leave the eye. The optic disc is a direct communication between the CNS (and therefore the cranial vault) and the eye. Papilledema is when the disc is swollen and protruding into the eye and this indicates elevated intracranial pressure. That finding would be consistent with certain kinds of hydrocephalus. I don't want to put words in his mouth, but I think that n@mdjd.com is saying the fact that papilledema hasn't been reported makes it less reasonable to conclude that she had the type of hydrocephalus that CBB postulated.

[n@mdjd]

The question about papilledema relates to the time of the first two CT scans. CBB, in the course of discussing the "impossibility" of a normal CT has mentioned the occasional dramatic use of decompressive craniotomy or craniectomy as an adjunct to the medical treatment of marked increases in intracranial pressure (ICP). Evaluation of the eye for papilledema (as described by med student) is a standard technique incorporated into the physical examination to assess whether intracranial pressure is significantly elevated, and I just wondered whether TS's physical exam showed such evidence of increased ICP at about the time the initial CT's were obtained.

[n@mdjd]

The question about papilledema relates to the time of the first two CT scans. CBB, in the course of discussing the "impossibility" of a normal CT has mentioned the occasional dramatic use of decompressive craniotomy or craniectomy as an adjunct to the medical treatment of marked increases in intracranial pressure (ICP). Evaluation of the eye for papilledema (as described by med student) is a standard technique incorporated into the physical examination to assess whether intracranial pressure is significantly elevated, and I just wondered whether TS's physical exam showed such evidence of increased ICP at about the time the initial CT's were obtained.

[purple_kangaroo]

retired_doc, I think it was you that said bulemia didn't necessarily include purging. Could you provide soem resources for that? I've worked with people with addictions and eating disorders and have never heard that before.

I do know that, IF it's severe and has been going on for a long time, a serious eating disorder can affect a person's teeth and general health by their mid-twenties . . . I've seen it happen. I don't know about bones, but if anorexic patients have a serious calcuim definciency because of their diet, I know it can cause problems with their teeth not being as dense.

But I do find it very odd, if Terri's bones were affected, that a bone-density test or other tests along that line were never done or, if they were, never mentioned. Wouldn't that be standard protocol when finding out someone had a lot of bone activity--to run some tests to try to find out why?

I appreciate the studies and information n@mjdj has provided . . . they help to provide a fuller picture of the different elements and how they can work together.

[retired doc]

Purple-, I believe that the post you were asking about was from med student. But I tend to agree with what he said.
--Patients that are paralysed or bedfast generally develop osteopenia. There would be no reason to test for this. Its presence would be a given.
--Have you seen the posts by the radiologist, Dr. Kate Killebrew, located toward the end of the initial discussion of the bone scan?

[ddb]

I see lots of discussion about osteoporosis, Terri's age, and the like.

Like I said in another post, there is no guarantee that the nuclear bone scan was even Terri's.

The deposition from the radiologist shows he does not even take responsibility for the final report of that nuclear scan. Those are not his initials - neither set - on that report.

Now, as I tried to explain - the probability that a radiologist "read" a scan that did not even go to the correct patient is overwhelming and if you have ever worked behind the scenes in radiology departments you know what I talking about.

At this point - there is no chance - ZIP - of ever verifying that the scan was her's - TERRI IS GONE. Her bones are burned up.

But to tell you the truth, that doctor could have been reading the scan of an 80 yo lady with Terri's name on the paperwork - or he could have been reading the requisition of Terri's and picked up a different scan and read it - never looking at the name on the actual scan on the board. The tech could have put the wrong requisition info on the wrong things for the doctor to read. The areas of probable error are GREAT!

It was so very important that Terri be examined while she was alive but of course the powers that be would not allow it.

But first road block for me is - that nuclear scan may not have even been Terri's. Not the one that has her name on it - or the report that was typed with her name on it - Do you see what I'm saying?

And since there keeps being talk of osteoporosis on it and there is never mention of the skull and yet it says on it clearly "closed head injury" - I very much doubt all is right with this nuclear bone scan FROM THE GET-GO. So "reading it" does nothing. This argument is tainted from the start.

:(((

[retired doc]

ddb, I believe that a complete set of xrays was performed in conjunction with the autopsy. They should show the minor compression fracture of L1. It will be interesting to see if these xrays show evidence of other healed fractures.

[Jeremy]

Purple Kangaroo...yes there are two types of bulimia. The purging and non-purging kind. But instead of you having to rely on me to explain my psychopath notes...I give you:

http://www.emedicine.com/med/topic255.htm

[purple_kangaroo]

Jeremy, thanks for finding that article. So bulemia is technically, according to that article, any instance in which someone regularly binges and then tries to make up for it in some way, whether by exercising, purging or whatever. But the fact that most of us eat a big meal occasionally (especially on holidays) and then try to counterbalance that with exercise or limiting calories doesn't make us all bulemic:

"DSM-IV diagnostic criteria require episodes of binge eating that occur at least twice weekly for 3 months."

The problem is that there doesn't seem to be any evidence of regular binge eating activity followed by purging type activities in Terri's case. That's why bulemia was never confirmed.

I think it's inarguable that Terri was having some health issues and not feeling well before her collapse. At a minimum, she'd had (according to publicly available court and medical records):

*At least one missed period (not necessarily indicative of a problem in itself)

*At least a couple of pretty severe fainting spells

*A serious vaginal infection and a reaction to the medication for it

*A diet, at least in recent days, which apparently consisted of taking in very little nutrition and drinking large amounts of beverages (cola, iced tea) which tend to have an upsetting factor on the body's mineral balance when consumed in large amounts.

*Possibly had symptoms of nutritional deficiency and mineral imbalance.

She really should have been under the care of a doctor and having a battery of tests run even with just that combination of symptoms. She also should have been dieting under the care and advice of a doctor, who was making sure that she was taking a multivitamin and not carrying it to a dangerous level.

I believe that's why she won the malpractice suit, isn't it?--not because they proved she had bulemia and it wasn't diagnosed, but because she had a collection of troublesome symptoms that should have initiated some diagnostic testing and discussions about her eating habits, etc. and apparently the doctors she was seeing didn't catch that and act on it for whatever reason.

However, it seems that she wasn't really the type to easily go to a doctor about her health. The fact that she simply stopped taking the medicine for the vaginal infection and didn't go back in to her doctor for a follow-up after she had the allergic reaction to it would seem to indicate that. I know she was seeing a gynecologist for help getting pregnant, but had she talked to a doctor about all the other issues? If not, we can hardly blame that on the doctors.

The problem is, because there weren't tests run and all the evidence doesn't seem to fit any one hypothesis of a health problem, we may never know exactly what caused her collapse and brain damage.

Because the testimony of the only person besides Terri who was there is different every time he tells the story, we can't even be sure about when she collapsed or what that collapse was like.

[ddb]

I'm just going to throw this out here and you all can shoot it down.

Terri had trouble getting pregnant - at least this is what I have read and MS seems to reiterate.

There has been a report that she had a drug in the kitchen she had been prescribed "to make her ovulate more" (?) something like that. (those fertility drugs are difficult to take and expensive from what I know about them). If MS was as "cheeep" as he comes across, I wonder if there really was such a drug there. But if there was, were any missing? She had supposedly not started them yet.

Something that just sits in my mind is I wonder if she had polycystic ovaries? Was that ever determined anywhere? From her coloring and pictures this has crossed my mind a couple of times. Her body habitus, coloring, and her weight - make me think that.

She had weight issues, and she had pregnancy issues - that sometimes comes with polycystic ovaries.

This doesn't mean a hill of beans here except that I thought it from her dark eyebrows and her picture.

Yes, retired doc, thanks - I saw that reference to there being correlating x-rays done......and was wishing I could see them talked about in the same breath as the nuclear scan. You know, referenced back and forth from the scan better.

Back to the medicine Terri had - I read that she had not started the fertility medicine so that's why I didn't put it into my ideas to consider (like Clomid and all those) and their side effects.

I'm still stymied on WHO PUT OUT THE WORD THAT SHE WAS BULIMIC?

If it was a doctor that is trustworthy who had been seeing her and if we know she had told him what she was doing of either purging or drinking lots of fluids or both (gosh she should have been dead already if she did both!) - then maybe I will buy the bulimia.

However, if bulimia is something Michael Schiavo managed to get out there or put into the minds of the medics from that night - I am having a problem with trying to put her symptoms off on bulimia.

[zheka]

med student, n@mdjd

got it
thank you

[purple_kangaroo]

Codeblue, I don't think you saw this question earlier, so I'm reposting it for you. Thanks.

"Codeblue, thanks for your post and for raising some of these questions. I was wondering if by any chance you might have even just one of those CT scans similar to and one worse than Terri's, with a very brief case history of the patients, that you might be willing to allow me to add to my collection of abnormal CAT scans compared to Terri's on my site here: http://www.xanga.com/item.aspx?user=purple_kangaroo_Angela&tab=weblogs&uid=235615226

Also, I was wondering . . . if someone does take you up on your challenge, where will you get the 100 CT scans? Would they come from patients you have seen (wouldn't that create a legal problem, or would you have all 100 patients sign waivers allowing you to make parts of their medical records public?), or would they be more like public-domain textbook pictures?

Anyway, I do appreciate your whetting my interest in the physical attributes and functioning of the human brain, and how it relates to Terri's case. I know a lot more about it now than I did a couple of weeks ago."

Thanks!