CSI MEDBLOGS: FURTHER INVESTIGATION OF CT BRAINS TURNS UP NEW ASTOUNDING EVIDENCE

Terri Did Not Suffer Her Brain Damage Outside The Hospital--It Occurred While She Was Hospitalized

According to a time-line of physicians and therapists reports, posted on The Empire Journal, Terri's injury occurred on 2/25/90:

2/25/1990		Terri's Injury
2/25/1990	X-Ray Report Dr. Hameroff	Images taken of cervical spine, no acute bony pathology - straightening of normal cervical lordosis
2/25/1990	Neuro Consult Dr. DeSousa	Deeply comatose.  No evidence of acute process in CT scan.  Evidence of myoclonic seizures.  Rule out acute myocardiac infarction, seizures as cause.  Neck is somewhat stiff as is all of the muscles of the body.  No jugular venous distension.  WBC 26,300, drug screen negative
2/25/1990	CT Scan Report Dr. Hameroff	Normal
2/26/1990	EEG Report Dr.  DeSousa	Abnormal EEG indicative of generalized suppression and slowing
2/27/1990	DeSousa Report	Brainstem Auditory Evoked Response shows no significant disruption of the brain stem acoustic pathway - study within normal limits
2/27/1990	CT Scan Report Dr. Greenberg	Normal CT Scan
2/28/1990	EEG Report Dr. DeSousa	Generalized diffuse slowing.  Some fast frequency rhythms which were not obvious during previous recording.  May have been slight improvement over last EEG.
3/19/1990	EEG Report Dr. DeSousa	Markedly abnormal EEG, no significant improvement from previous records
3/30/1990	CT Scan Report Dr. Abramson	CT Scan shows noncommunicating hydrocephalus, changes occurred since 2/27 exam

If you look carefully at this time line you will see that Terri had "NORMAL" CT's of the brain on 2/25 and 2/27.

STOP THE PRESSES

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

NO WAY

Brain edema begins to occur about 20 minutes after infarction and by 24 hours her brain (if she HAD suffered a massive anoxic event) would have been MASSIVELY SWOLLEN -- something that could NEVER be missed and NEVER called normal.

NEVER.

If Terri's brain CT was NORMAL 2 days after she entered the hospital than there is NO POSSIBLE WAY she suffered a massive infarction or global ischemia on 2/25.

THIS IS ALL WRONG

Now look at 3/30. Suddenly she develops NONCOMMUNICATING HYDROCEPHALUS.

WHAT?

Did anyone ask HOW? How did she develop noncommunicating hydrocephalus suddenly on 3/30/90 with 2 normal CT scans on 2/235 and 2/27??

CONCLUSIONS?

1. IF this is an accurate report (normal CT brain on 2/27 -- injury on 2/25) then  TERRI DID NOT suffer an event of massive ischemia on 2/25. tHERE IS NO RADIOLOGIST OR NEUROLOGIST OR NEUROSURGEON IN THE WORLD THAT WOULD DISPUTE THIS. it is impossible. tHE ct ON 2/27 WOULD HAVE BEEN grossly ABNORMAL.

2. IF TERRI DID NOT SUFFER ANOXIC DAMAGE ON 2/25 THEN THE REASON FOR HER BRAIN ATROPHY WAS CAUSED BY SOMETHING THAT OCCURRED after 2/25 namely in the hospital during February or march of 1990.

3. How does one develop NONCOMMUNICATING HYDROCEPHALUS in ONE MONTH? By a blood clot obstructing the CSF outflow from the brain at the Foramen of Magendie.

4. How does one get #3.

BY BEING HIT ON THE HEAD AND SUFFERING INTRACRANIAL HEMORRHAGE.

So Terri WAS HIT ON THE HEAD OR DROPPED ON HER HEAD DURING LATER FEBRUARY OR EARLY MARCH WHILE IN THAT HOSPITAL.

Comments

[Alan Betensley]

Global cerebral ischemia does not typically lead to massive cerebral edema. More often than not, the CT scan after this event is normal. Because imaging cannot demonstrate the extent of damage, physicians actually use the physical exam to evaluate brainstem reflexes to determine the extent of injury. Although this does not apply to Terri, the declaration of brain death relies on physical exam findings and does not involve any imaging studies.

[Ceci]

Could someone else comment on this? I'm not a doc, but it appears to me that one person is saying swelling will happen within minutes, while another one is saying that that it may not happen at all. I'm confused!

[stacey]

I think it is not a good idea for a doctor to be writing a diagnosis or interpretation based on what he reads from the interpretation by another doctor. I think this guy would lose his license if he did this in the field. This doc is all talk, and no experience in this case. If he gets these CT's to evaluate, then we should listen. But they way he has written this determination is just tabloid fodder.

[nerissa]

If they (hospice) are ignoring Terri's basic needs--shouldn't they be shut-down or have the Federal gov. and run things until they are ship-shape.

[nerissa]

If they (hospice) are ignoring Terri's basic needs--shouldn't they be shut-down or have the Federal gov. and run things until they are ship-shape.

[maximumbob]

RE: The Empire Journal
Do you think this is a valid summary of events, or a slanted/altered interpretation of events? It's not a real medical record, that seems obvious. What about the source? Lastly, any opinions about the 7/24/1990 MRI Report Dr. Pinkston
(Profound atrophy w/ very atrophic appearing cortex.  Mild white matter disease, anoxic/hypoxic injury)? We all want to see that MRI, so why has everyone concluded that there isn't one? Contradictions ad infinitum!

[MaxedOutMama]

Isn't that an abnormally high white blood cell count on admission? If you are going to speculate, at least include the possibility that she had an infection which produced incremental damage, perhaps? Or perhaps produced vasculitis, possibly causing a blood clot? The level of problems she quickly developed with her knees could be indicative of low level infection of some sort, perhaps not reliably showing on blood tests due to steroids used to control inflammation? The woman was in her 20's but she quickly developed arthritis in her knees (end of Feb admitted, beg. of May knee fusion - about 2 months). Her knees were treated with Keflex for at least once early in 1991 according to the records linked. Of course that WBC could have been totally unrelated and she could have picked up an infection in the hospital also.

There is no proof at all that Michael is responsible for all this. None. People shouldn't leap to these conclusions. We're never going to know exactly what happened. I'm not a doctor, but I've worked with vets to try to even get a good diagnosis on 2 different dogs with sudden onset of both extreme neuro symptoms that looked like some sort of stroke WITH arthritis and I have learned the limits of medical certainty. The one thing I know is that it was not due to the dogs being beaten, and the final best guess (after 2 good recoveries) was "disseminated infection".

This layman interpreted that as "God only knows, but antibiotics sure produced remarkable results". I'm not saying that this was Terri's problem - I'm just saying that medical mysteries abound. Whatever happened to her was unusual, but I doubt she was beaten up in the hospital while in the ICU.

[maximumbob]

RE: Ceci - read the disclaimer for this blog. Blogs by definition are thoughts & opinions offered by the blogger. It's like the TV, if you are offended or have a problem with the content, TURN IT OFF!

[bioethics dude]

Once again, WHAT IS THIS INFORMATION BASED ON?! I saw that the Empire Journal is cited, but they don't exactly 1) seem all that credible; and 2) note how or from where they obtained it.

[Ceci]

Maximumbob...

Huh? You must have me confused with someone else. I just said I was confused about the contradictory interpretation. I didn't say I was offended. I know there are people who post here that have medical experience, so I questioned the contradiction in the hopes that some of them would chime in and give me a little bit more data to chew on.

[Ceci]

Maximumbob,
Oh...I just figured it out...you must think I'm stacey. The names of the posters are below the post, not above.

[maximumbob]

RE: Eating Disorders - Wouldn't Terry's reported eating disorder (I believe the principle misdiagnosis in the malpractice suit that supplied the million dollars - the proported impetus for the demise of Terry) provide clues about her strange bone scan?

Just in - Supreme Court rejects Schiavo case!

[maximumbob]

Ceci - Sorry, I'm new here.

[Ceci]

Since I'm not a doc, I dont know the possibility of this, but if she had an long term intense diet bordering on anorexia/bulimia, can this eventually lead to seizures? The report of the incident stated that she fell in the bathroom doorway and was partially in the hall. If she had a seizure, that would be in a very confined space and could cause head injury and possible broken or damaged bones.

Just wondering.

[maximumbob]

Terry's MI was probably caused by hypokalemia (or low potassium levels) due to an electrolye imbalance as a result of her eating disorder (anorexia/bulimia).

From http://www.nlm.nih.gov/medlineplus/ency/article/003484.htm

"Potassium (K+) is the major positive ion within cells and is particularly important for maintaining the electric charge on the cell membrane. This charge allows nerves and muscles to communicate and is necessary for transporting nutrients into cells and waste products out of the cell. The concentration of potassium inside cells is about 30 times that in the blood and other fluids outside of cells.

Potassium levels are mainly controlled by the steroid hormone aldosterone. (For more information see the aldosterone test.) Aldosterone is secreted from the adrenal gland when levels of potassium increase. Aldosterone, in turn, causes the body to rid itself of the excess potassium.

Metabolic acidosis (for example, caused by uncontrolled diabetes) or alkalosis (for example, caused by excess vomiting) can affect blood potassium.

Small changes in the potassium concentration outside cells can have substantial effects on the activity of nerves and muscles. This is particularly true of heart muscle. Low levels of potassium cause increased activity (which can lead to an irregular heartbeat), whereas high levels cause decreased activity. Either situation can lead to cardiac arrest in some circumstances.

In normal people, taking potassium supplements or potassium-containing drugs is of no consequences, because the kidneys efficiently dispose of excess potassium."

The irony is that Terry may very well die from a form of the disorder that put her in this situation originally.

On the Bone: Calcium leaching from bone to blood du to S/S of an eating disorder can lead to Osteoporosis, a possible explanation for such extensive bone damage if Terry was dropped (likely) or cracked on the head (unlikely)

[Ed Jordan]

Three out of four board-certified neurologists say Terri can't be PVS based on an audio recording. The fourth says he would want to see video as well.

http://www.dawneden.com/2005/03/neurologists-tape-proves-terris-not.html

[Jeremy]

If her injury was on the 25th, it's perfectly reasonable that her 25th CT would be normal. It takes several days for the global changes to occur. It takes 12-24 hours for the microscopic changes and 24-48 hours for the softening and edema of the brain. I don't know when that would begin to show on CT but I find in reasonable to assume it would take days for that to show---assuming a global hypoxic-ischemic insult.

Of course, I'm reading all this from my medical pathology book. And I'm not a doctor...yet. But I don't find it hard to believe that it took over 2 days for gross CT changes to occur--it takes time for tissue to atrophy/die/etc.

Unsure about the noncommunicating hydrocephalus.

[maximumbob]

RE: EEG-Scan,Schmam-The EEG is probably the acurate indicator of CNS function as indicated by neural electrical activity based on comparissons of archived EEG's for well over 75 years. Based on this, coupled with the Empire Journal Report (if accurate), wouldn't it be prudent to conclude that Terry has only sub-cortical function?(see EEG reports at the bottom) Also, if we introduce additional info. from the same report (7/24/1990 MRI Report Dr. Pinkston-Profound atrophy w/ very atrophic appearing cortex.  Mild white matter disease, anoxic/hpoxic injury) can't we further conclude the same? This might satisfy one of Codeblue's criteria (* If Terri were actually brain dead (as opposed to brain damaged), or terminally ill, or mortally injured) to allow Terri Schiavo die. The only further test that would show conclusively whether or not cortical function is apparent would be a PET scan - showing uptake of radiotraced glucose as a function of active metabolism in active areas of the brain. I'm not sure that even this would suffice, as the bridge between objectivity & subjectivity has been crossed & burned!

From http://www.bio-medical.com/EEG.html

EEG History: The presence of electrical current in the brain was discovered by an English physician, Richard Caton, in 1875.  It was not until 1924 that Hans Berger, a German neurologist, used his ordinary radio equipment to amplify the brain's electrical activity so that he could record it on graph paper. Berger noticed that rhythmic changes (brain waves) varied with the individual's state of consciousness.

The various regions of the brain do not emit the same brain wave frequency simultaneously. An EEG electrode placed on the scalp would pick up many waves with different characteristics. This has presented a great deal of difficulty to researchers trying to interpret the large amount of data they receive from even one EEG recording.Brain waves have been categorized into four basic groups: Alpha, Beta, Theta, & Delta waves. Although none of these waves is ever emitted alone, the state of consciousness of the individual may make one frequency more pronounced than the others.

2/26/1990
EEG Report Dr.  DeSousa
Abnormal EEG indicative of generalized suppression and slowing

2/28/1990 EEG Report Dr. DeSousa
Generalized diffuse slowing.  Some fast frequency rhythms which were not obvious during previous recording.  May have been slight improvement over last EEG.

3/19/1990 EEG Report Dr. DeSousa
Markedly abnormal EEG, no significant improvement from previous records

4/4/1990 EEG Report Dr. DeSousa
No significant change since last EEG.  Does not seem to indicate paroxsymal activity.

[Ceci]

I hope y'all don't mind my asking this. It's more about methodology that this particular case.

Apparently Dr. Cranford felt an accurate diagnosis could be reached without MRI or PET scans. Will using CT scans, EEG, and physical examination allow one to conclude someone is vegetative? Does this hold true in all cases, or are there a few instances where more elaborate tests along with rehab are needed? Is there a *standard* methodology used in medicine to diagnose someone as PVS?

I think somewhere around 1999 Florida decided that feeding tubes were life support and could be withdrawn. Coupled with the guardianship laws of the state, it's perfectly legal to dehydrate someone to death with a diagnosis of vegetative.

Now, prior to this date, the diagnosis of vegetative may not have caused such an unalterable conclusion as death. Should the medical community be notified of legal changes such as those made in Florida so they can decide whether the standard of evidence for PVS should be raised due to a grossly different potential outcome?

[Elizabeth]

The Sun Sentinel has posted this Graphic of Terri's CT X-ray scan from her medical records, detailing their analysis of what it shows. http://www.sun-sentinel.com/news/local/southflorida/sfl-0324ctscan_graphic,0,6028609.graphic

Along with this article:
"Neurologists disagree with state specialist on Terri's brain damage

"Scans of Terri Schiavo's brain show that the great majority of her gray matter where thinking and feeling occur has died off and been replaced by watery fluid, with no chance of growing back, neurologists said.

About 70 percent to 90 percent of Schiavo's upper brain is gone, and there's also damage to her lower brain that controls instinctive functions such as breathing and swallowing, said three Florida neurologists who viewed 12 of her CT "computed tomography" X-ray scans Tuesday and Wednesday.

"This is as severe brain damage as I've ever seen," said Dr. Leon Prockop, a professor and former chairman of neurology at the University of South Florida College of Medicine in Tampa, upon viewing the scans.

Dr. Walter Bradley, chairman of neurology at the University of Miami's Miller School of Medicine, added: "I doubt there's any activity going on in the higher levels of her brain."

Read entire article here. http://www.sun-sentinel.com/news/local/southflorida/sfl-rxct24mar24,0,6305655.story

I have no experience in the medical field, so I can not comment on the doctor's opinions in the article. However I was wondering what you guys thought about their analysis. I also have some questions regarding these comments.

"Neurons do not grow back. The brain can rewire itself so that remaining healthy tissues take over functions that had been done by the cells that died. But if that were happening, it would have shown in Schiavo's behavior by now, said Dr. Michael T. Pulley, an assistant neurology professor at Shands Jacksonville Hospital, affiliated with the University of Florida medical school.

"The chance that this person is going to recover is about zero," Pulley said. "The longer a person goes on, the less likely it is they will recover."

Is this true, that the brain can "rewire" itself? And to what degree of certainty can they say that, this is not happening in Terry, if none of these doctors have observed her behavior over the last 15 years?

Elizabeth

[Elizabeth]

Here's Terry Schiavo's discharge summary from Humana Northside Hospital detailing her symptoms, changes in her condition, and results of tests run. I have no idea what any of this means, but I figured you guys may find it interesting.

http://www.zimp.org/stuff/Discharge Summary 050990.pdf

Well, MaxBob, soon you'll get your wish. She'll be dead and then there will be no way to examine or test her. How nice for you.

[Craig H]

So your theory is that she developed noncommunicating hydrocephaus from a hemorrhage. Blood clotting up the foramen of Magendie any other blood in the ventricles? Without any evidence of subarrachnoid blood? Kinda curious, don't you think, the lack of any mention of blood on a study that's pretty good at detecting the presence of blood.

And all this from interpreting the one line summaries of other docs' interpretations as reported in a non-medical record. This is pretty insubstantial stuff for the kind of absolute claims made above. Authority and credibility on a subject is earned, and this is not the way to go about it.

Jeez Craig, lighten up. I don't think the dude is trying to be an authority on anything. He just seems to be asking a lot of questions that noboby else seems to be asking. That, in itself, should be a positive thing.

[Craig H]

"tHERE IS NO RADIOLOGIST OR NEUROLOGIST OR NEUROSURGEON IN THE WORLD THAT WOULD DISPUTE THIS." Hmm. Sounds pretty authoritative.

Don't get me wrong -- I think the question-asking is great. I'd just be way more careful about the certainty of the answers at a time when folks are looking hard for new information to hang their hopes on. I'll be glad to lighten up when the issue isn't as pressing.