CODEBLUEBLOG ANALYZES TERRI SCHIAVO'S CT OF THE BRAIN THIS BRAIN IS NOT THAT BAD

CSI Medbogs ^ | 03-25-05 | WL-Law

[WL-law]

CSI MEDBLOGS (THE AWARD WINNING MEDICAL WEBLOG):

CT scan of Ms. Schiavo's brain, showing extensive cortical regions filled with spinal fluid.

...

A COURT OF MEDICAL LIGHTWEIGHTS WEIGH IN ON TERRI'S CT. The Second District's first opinion in this case explained:

"Since 1990, Theresa has lived in nursing homes with constant care. She is fed and hydrated by tubes. The staff changes her diapers regularly. She has had numerous health problems, but none have been life threatening.

Over the span of this last decade, Theresa's brain has deteriorated because of the lack of oxygen it suffered at the time of the heart attack. By mid 1996, the CAT scans of her brain showed a severely abnormal structure. At this point, much of her cerebral cortex is simply gone and has been replaced by cerebral spinal fluid. Medicine cannot cure this condition. Unless an act of God, a true miracle, were to recreate her brain, Theresa will always remain in an unconscious, reflexive state, totally dependent upon others to feed her and care for her most private needs."

First, I contest the theory that Terri's brain actively continues to degenerate as implied by the above statement. How could they gage serial brain degeneration without serial follow-up? And by what mechanism would her brain CONTINUE to atrophy?

Second, Terri's cerebral cortex has not been replaced by fluid. That is inaccurate. The cortex is thinned and the sulci are enlarged. There is a difference.

Third, and most importantly, given the amount of atrophy on this image I disagree with the court's inadequately considered conclusion.

My Grandmother's Brain -- OK -- But Would I Stop Feeding My Grandmother?

First of all, the University of Miami's appellation for this scan is inaccurate. "Cortical regions" are not and can not be filled with spinal fluid. The sulci (spaces between cortical ribbons) are enlarged secondary to cortical atrophy and these sulci are filled with cerbrospinal fluid.

The most alarming thing about this image, however, is that there certainly is cortex left. Granted, it is severely thinned, especially for Terri's age, but I would be nonplussed if you told me that this was a 75 year old female who was somewhat senile but fully functional, and I defy a radiologist anywhere to contest that.

I HAVE SEEN MANY WALKING, TALKING, FAIRLY COHERENT PEOPLE WITH WORSE CEREBRAL/CORTICAL ATROPHY. THEREFORE, THIS IS IN NO WAY PRIMA FACIE EVIDENCE THAT TERRI SCHIAVO'S MENTAL ABILITIES OR/OR CAPABILITIES ARE COMPLETELY ERADICATED. I CANNOT BELIEVE SUCH TESTIMONY HAS BEEN GIVEN ON THE BASIS OF THIS SCAN.

The worrisome, no alarming thing, for me, was that I heard a bioethicist and several important figures on the major media describe Terri's brain as MUCH WORSE. One "expert" said that she had a "bag of water" in her head. Several experts described her as a "brain stem preparation"

These statements are wholly inaccurate. This is an atrophied brain, yes, but there is cortex remaining, and where there's cortex (?life) there's hope.

If you starve this woman to death it would be, in my professional and experienced medical opinion, the equivalent of starving to death a 75-85 year old person. I would take that to the witness stand.

All That Glitters is a SHUNT

Next mystery: Why is there a shunt in Terri's ventricle? This CT image is "flipped" (i.e. the CT scan is mirror-image backwards which is just an inconsequential error made when scanning the image into the computer), so the right side is LEFT and vice versa. However, everyone can see, easily, the ovoid white object sitting in the front of the big black butterfly in the center of Terri's brain, correct? That shining object is the tip of a shunt.

A shunt is a tube inserted into the brain to reduce pressure caused by build-up of cerebrospinal fluid (CSF) in the brain. That big black butterfly in the middle of Terri's brain is her ventricular system, which holds the CSF and in Terri's case, it is enlarged (dilated).

Now...why was Terri being shunted in 1996? First, if Terri's brain damage was due to oxygen deprivation, her enlarged ventricles would be by a passive mechanism -- which is not amenable to shunting -- not by obstruction of the egress of CSF. To me, the presence of a shunt indicates obstruction to the flow of CSF that needs to be circumvented. Obstruction to flow is hard to postulate given the mechanism of Terri's brain injury (oxygen deprivation).

It would NOT be hard to postulate, however, if she had BLOOD in her head at some point in the past. So did she? Was there a history of trauma? I would like to see the BONE SCAN taken of Terri that purportedly showed evidence of traumatic type osseous uptake!

It is quite unusual to see high-pressure hydrocephalus when the mechanism of brain injury was INFARCTION; and, more so six years after the event.

So IS THIS REALLY TERRI'S CT?

IF it is then her atrophy is SEVERE, BUT not as bad as has been implicated by the press and the courts IF it is then why did she have hydrocephalus six years after her non traumatic infarction

IF it is... why was she shunted...AND IS SHE STILL shunted? IF not, why was the shunt removed?

IF it is, why does the Second District Court NOT mention Terri's hydrocephalus in it's dissertation on Terri's woeful cerebral condition??

IF Terri DOES have hydrocephalus from ventricle blockage, was there trauma that caused bleeding that lead to hydrocephalus on the basis of a blood clot obstructing ventricular outflow?

IF so, what was that trauma?

IF Terri had hydrocephalus in 1996, she may still have hydrocephalus now; some patients with hydrocephalus respond to shunting with increased mental functioning! IF THIS IS NOT TERRI'S CT THEN WHERE IS HER CT?

Based on this evidence Terri Schiavo should have a CT scan repeated. She should also have an MRI and a PET scan to gage the severity of her brain dysfunction. IF THIS IS TERRI'S CT OF THE BRAIN, SOMETHING MAY BE VERY WRONG

CSI MEDBLOGS: CODEBLUEBLOG ANALYZES TERRI SCHIAVO'S STARTLING BONE SCAN

WHAT DOES TERRI'S BONE SCAN MEAN? It is my opinion that the most likely reason for these bone scan findings in March of 1991 is that someone either was physically abusing Terri or they dropped/mishandled her severely. A reader asked me to comment on Terri Schiavo's bone scan report.

Here are my initial thoughts:

It is perilous to try and interpret just the bone scan REPORT. I need to see the scan itself and the correlative X-rays.

However, that being said, several things are unusual.

First, the DATE on this bone scan is March 1991. Terri's cardiopulmonary arrest -- as far as I can tell -- was in February 1990; therefore, the abnormalities that are described occured AFTER Terri's February 1990 arrest, probably in the weeks or month(s) just prior to the bone scan, unless she had a second arrest at some point -- and I do not have that history. Certainly there was trauma. As I understand it, the issue is how the trauma occurred.

Trauma from CPR generally involves the anterior aspects of the ribs where they join the sternum. This is usually due to vigorous compression during CPR. Any other proposed trauma during CPR would need to be documented by the notes or by eye witnesses as to the mechanism (e.g.: did she fall off the stretcher?).

The bone scan report of TS describes an injury NOT to the anterior ribs, but, to a different part of the ribs-- posteriorly -- namely at the juncture of the ribs and vertebrae (the costovertebral juncture, or CVJ).

In addition, although the report mentions several rib fractures, it does not specify if they were all CVJ located or in different/various locations. This is important.

Finally, I do not see a report of correlative x-rays for the ribs, which would be helpful to determine the TIMING of the injury (fractures look very different depending on WHEN they occurred).

The compression fracture of L-1 is interesting. This is certainly NOT a typical injury that occurs during CPR as it generally involves an AXIAL load (i.e. on the top of the head; or from the top DOWN); a caveat here: if TS was anorectic for a prolonged period or on certain medications she could have been osteoporotic, in which case some might claim that a mild compression fracture of L-1 would not be so unusual-- however this is only true in ambulatory people, which Terri was not.

The uptake over Terri's distal right femur is the most peculiar element in this report. This is an unusual finding in ANY situation and I would have to see the scan and films to be sure of what it means; however, if there is PERIOSTEAL ELEVATION then one would have to posit (as did the person who interpreted Terri's bone scan) the possibility of bleeding underneath the thin covering of the bone (the periosteum) which is a finding that correlates highly with trauma, specifically, abuse.

It would be difficult to propose a mechanism that caused this type of problem unless a specific witness arises to declare he or she remembers a specific event that would have caused this UNUSUAL finding.

I would want to know if Terri had a BLEEDING problem at any time, because that might explain this finding. Certainly IN A CHILD (which Schiavo, obviously was not), the combination of posterior rib fractures, vertebral compression fractures, and distal femoral periosteal elevation is ABSOLUTELY POSITIVELY DIAGNOSTIC for child abuse and any radiologist who missed this diagnosis would be subject to disciplinary action from his peers and state licensing board. SEE: http://radiographics.rsnajnls.org/cgi/content/full/23/4/811

It is my opinion that the most likely reason for these bone scan findings in March of 1991 is that someone either was physically abusing Terri or they dropped/mishandled her severely.

The x-rays might make all of this clearer if we can obtain them. n.b.

Teri's fractures could be of the "insufficiency" type (caused by prolonged immobilization/dietary irregularities) and some might posit this explanation; however, in a nonambulatory bedridden patient under careful supervision, I find this untenable, especially given their distribution which are so typical for ABUSE.

Here's the link to the bone scan report: http://www.terrisfight.org/images/bonescan

[petro45acp]

So, are you saying that even with a flat-lined EEG, there could still be cogitation? Left lobe Right lobe interaction?
Learning?

[beyond the sea]

However I did have to search a bit for a pic that wouldn't scare any children.

LOL!

[massgopguy]

Judge Greer needs to destroy the evidence in the Medicaid Fraud scheme that he is knee deep in. HHS should issue a Cease and Desist Order while they prosecute Suncoast Hospice and its Board of Directors.

[Diogenesis]

A bowl of jello puts out a pseudoEEG signal. Sounds like the leads were not attached.

Also, FWIW, CO2 in excess makes the EEG flat, too. [beware dry ice inhalers]

[WL-law]

I'm saying I don't believe the EEG, and the PET scan would provide real solid data and "proof".

[philomath]

saw it.

now i understand what you're saying about the sidedness. the writing on the film is reversed so we are getting a top-down (looking from above the head toward the feet) view.

i agree with you: this scan in and of itself doesn't tell us much about whether terri is conscious in any sense.

problem i have with PET is that detractors would say that lighted-up areas are part of reflex circuits only. however, if language, motor, or premotor areas lit up, we would have strong evidence of consciousness.

agree also on the severity of injury: i have seen scans looking worse than this on people who were obviously conscious. is this the new cleansing criterion: starve you if a judge doesn't like the way your ct scan looks??? we aren't on the edge of the slippery slope; we're falling down it......

[glowworm]

Shades of the RatherGate memos.. I just don't trust that any of them are really Terri's but someone simular.. Is there a trail of custody involved.? I guess I have seen medical errors in taking off someone's wrong leg.. And these ppl have a mission.

[little jeremiah]

And I read the exact opposite.

You want to think that the "occupant has left the tent." Well, she's about to leave now, thanks to attitudes such as yours.

[oldcomputerguy]

"An EEG is NOT an accurate tool, by any means, to make this kind of determination. Not even close"

Disregarding PET scans and MRIs, what would a flat-lined cerebral cortex EEG tell you?

[glowworm]

There is a statement that her head may have been bashed in 3 days after she was brought in from the collaspe. Maybe it may show those kind of injurys that are not documented.. that could explain a lot of unknowns.. But then.. I am not a dr.

[Havoc]

You know, this is getting more and more like having a guy argue with you that your car can't be running because on paper it's totalled.. even while he stares at the running vehicle..

[WL-law]

Disregarding PET scans and MRIs, what would a flat-lined cerebral cortex EEG tell you?

There's a principle in law called "the best evidence rule".

Now, it's not about EEGs vrs CAT/PET scans, it's about documents, but there is a similar point to be made in this instance.

The point is this: would you be willing to make a life-or-death decision on less-than-the-best evidence, when the best evidence is available?

Of course not.

Given the range of affidavits and observations from caregivers, I simply refuse to believe the purported EEG results, and would demand corroberation using "the best evidence".

[oldcomputerguy]

"Now, it's not about EEGs vrs CAT/PET scans"

See, here is the problem, you purport to be degreed in the appropriate fields but have completely dodged the question I put to you because, I assume, it doesn't fit your hypothesis.

Lets go back to the original question, what would a flat-lined EEG tell you if it was the only test available, and in this case was the only test of that sort done to my knowledge?

Since you now say you refuse to believe the results I assume the actual reported results contradict your assertion completely.

And another question, since I have an expert like you at my disposal. What test is used to determine brain death in other patients on life support? Is it the EEG that you now disparage in the Schiavo case?

[brewcrew]

THIS BRAIN IS NOT THAT BAD

If it wasn't then, I'm sure it is now. Greer is seeing to that.

[WL-law]

See, here is the problem, you purport to be degreed in the appropriate fields but have completely dodged the question I put to you because, I assume, it doesn't fit your hypothesis.

Look, I defy you to go and read the following facts, laid out in a spreadsheet, and reach a conclusion that ANYTHING being said by Michael Schiavo's side is truthfuul.

Here;s the link:

http://www.zimp.org/stuff/contradictions.htm

What's going on is that there is now an unholy alliance between Michael Schiavo's obvious homicidal motive, on the one hand, and certain players (i.e., Dr Harrison) in the medical field that see the case as a platform to espouse and project their own ideas of managing Terri's demise.

It is Harrison (see the testimony in the link) who makes the read of the EEG -- and I just don't believe him, and moreover the video that I can see with my own eyes contradicts him, and the testimony of many other specialists as well.

PET scanning was in its infancy at that time period (early 90's) so it may not have been considered, and since the early 90's Michael Schiavo has been determined that NO tests, NO rehab, NO attempt to treat infections, be the rule.

[Lijahsbubbe]

Good post.

And even if she was horribly impaired, so what.

I heard one finding saying that she had no room for improvement, so what.

I'm sure at Judge Greer's age, there's no room for improvement either. From here on it's a physical decline for him. Should the starving of Greer begin also?

[Salvation]

BTTT!

[oldcomputerguy]

"It is Harrison (see the testimony in the link) who makes the read of the EEG -- and I just don't believe him,"'

So yet again you have dodged the rather simple question I posed to you about a flatlined EEG. And managed to avoid the second question about which test is used to determine brain death in other patients. While you got an A in English comp, I would have to give you an F in debate.

OK I quit now, on to other things, your postings or lack of them stand on their own.

[WL-law]

a flatlined EEG.

You're tiresome sa well, and I'm being charitable in my description of you.

I'll say it one more time, to address your puny arguments:

1) I don't believe the EEG report in the first place; and

2) in any event such as this one, where there are conflicting reports and contesting parties regarding the evidence, the BEST EVIDENCE should be required.

Whether EEGs are relied on in other situations, i.e., uncontested situations without conflicting parties or conflicting evidence, then less-than-the-best evidence may not raise any objections from the participants. That's irrelevant here.

Oh, by the way, as to your last point, I absolutely ENCOURAAGE you to find "other things" to do -- because if you can rationalize letting Terri die, your opinions on EVERYTHING ELSE are, frankly, forever worthless to me.