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Dr. F
Dr. F, Board Certified MD
Category: Neurology
Satisfied Customers: 266
Experience:  Neurosurgeon with more than 20 years experience in practice and teaching.
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I have a question about my moms recent brain injury. I am

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I have a question about my mom's recent brain injury. I am seeking for expert's input and explanation of the cause of her brain bleeding.
My mother is 71 years old. She had a Deep Brain Stimulation surgery (DBS) on 10/28/10 to treat her Parkinson's. The surgery went very well and she was kept in the hospital SICU for overnight monitoring. She was supposed to be discharged on 10/29/10 of no complication developed overnight. Unfortunately, she took a fall at 5am on 10/29/10 in hospital ICU room and hit the right side of her face pretty hard on the tiled floor. She had a CAT scan at 8am that morning and the brain image looked all normal at that time. Her right side of the face swelled up to double its size by the time she was discharged from hospital at 5:30pm that same day. Later she was found unconscious in bed at 8am on 10/30/10. She was then sent to ER and another CAT scan was done. The brain image showed a large area of bleeding found on the left frontal lobe of her brain. The doctor told us that this was called contusion. The bleeding was caused by bruising of the brain tissue as a result of the fall. I am wondering why 3 hrs after the fall the CAT scan didn't show any brain tissue abnormality? Is it common to have a delayed brain hematoma after a hard fall? based on your impression of the sequence of the events and the outcome, what's your key conclusion if you have to draw a logical one with regard to the cause of her bleeding? In another word, what do you think are the possible mechanisms or developmental stages involved that contribute to her bleeding? She did seem to be very unsettling and not verbalizing much the night of 10/29/10 after she arrived home. If without the fall, would you still think she would have the bleeding? I really apprecite your answer or your pointing me to the right direction to seek for an answer. Regards, XXXXX XXXXX is the radiologist's report based on CAT scan images: Report on 28/10 (pre-surgery): FINDINGS: Study was performed in a stereotactic frame which create extensive artifact on some slices. Ventricular size and position is normal with no acute hemorrhage obvious. IMPRESSION: Study limited as described demonstrating no acute change. Report on 29/10 (pne day after the surgery, 3 hrs after the fall): FINDINGS: There has been interval placement of bifrontal approch deep brain stimulator leads with the tips projecting in the bilateral mid brain. Streak artifact limits evaluation but no gross hemorrhage or large territory vascular infarct are identified. Postsurgical changes noted in the bilateral frontal calvarium. The paranasal sinuses and mastoid air cells are clear. The orbital contents are symmetric. The solf tissues are unremarkable. There are several small foci of pneumocephalus. The ventricles are of normal caliber. IMRESSION: Status-post deep brain stimulator lead placement as described. Reoprt on 10/30/10 (29 hrs after the fall when she was found in coma): FINDINGS: Artifact from deep brain stimulator is identified, similar to the prior examination. However, there has been interval development of a large left frontal intraparenchymal hemorrhage with a small arachnoid component with blood seen in the sylvian fissue. Mild left to right midline shift is identified, estimated at approximately 0.5 cm. No uncal herniation is seen. No acute large vessel territory stroke is identified. Utilizing bone window algorithms, postsurgical changes are seen. IMPRESSION: 1. Reidentification of leads from deep brain stimulators, similar position to the prior examination, with extensive associated edema. 2. Interval development of large left frontal intraparenchymal hemorrhage and small subarachnoid component with mild left to right midline shift.
Submitted: 3 years ago.
Category: Neurology
Expert:  Dr. F replied 3 years ago.

Dr. F :

Hi Bonnie, I am a neurosurgeon and will try to answer your question

Expert:  Dr. F replied 3 years ago.

I changed format, as I find this works better when the customer is off line

 

I am sorry for your mother's injury. I agree with the previous expert that the bleeding is likely from the fall, and not from the surgery, based on the location of the bleeding and the history of the fall.

 

The only additional information I would ask is whether she had some factor which would make her prone to bleed, such as the drugs aspirin , plavix or other anti-clotting agents. did she have normal ? Did she drink alcohol?

 

Delayed bleeding is something that does happen, and should be watched for, but a hospital which does not see a lot of patients with head trauma might not have the experience to know to watch for it.

 

I hope that helps

 

Thank you for the opportunity to help you. To give me credit for my time and effort, please press the ACCEPT button for this answer. After that, I will still be glad to answer additional questions until you are satisfied.

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This answer is for information only. It cannot and should not be substituted for or the recommendation of your doctor

Customer: replied 3 years ago.

Thank you so much, Dr. F!

My mother didn't take any anti-clotting drug per surgeon's instruction. She never drinks either. Based on your experience and practice in neurosurgery field have you ever seen similar cases before? Is this an unusual case hard to draw link between the cause (the fall) and the consequence (delayed bleeding)?

I will be sure to give you credit at the end.

Thanks again,

Bonnie

Customer: replied 3 years ago.

Dr. F,

Would you like to be contacted by my attorney?

I can be reached at five one three, five zero eight, seven four six zero.

 

Many thanks!

Bonnie

Expert:  Dr. F replied 3 years ago.

Thank you for the offer. I would like to help, but out "Expert Agreement" expressly prohibits that kind of interaction. We are limited in our contacts with customers to this forum alone.

 

 

 

 

Customer: replied 3 years ago.

Okay, Dr. F. I understand.

 

Since you are a neurosuegeon yourself, have you ever seen similar cases, i.e., delayed bleeding after an impact on the brain tissue, during your years of practice? If you had a patient took a fall after the brain surgery, would you have kept him/her for at least 24-hr of monitoring? You said that you agreed with another expert's opinion, which is that the bleeding is likely caused by the fall. Let's assume that you were an expert witness, how would you explain the mechanism led to her delayed bleeding? There are doctors in the hospital where my mom took the fall trying to tell our family that it's unusual that no abnormality was observed in CAT scan 3 hrs after the fall and bleeding occured later. I just want to understand what possibly happend in her brain between 3 hrs after the fall and 27 hrs after the fall when she entered a coma state. Do you agree that MRI would have shown abnormality 3 hrs after the fall although she couldn't have had one done due to the leads from DBS? Are there other methods might have shown abnormality than CAT scan alone 3 hrs after the fall?

 

Thanks again for your answers.

 

Bonnie

 

Expert:  Dr. F replied 3 years ago.

Welcome back, Bonnie

 

I have copied your question to answer it

 

Let's assume that you were an expert witness, how would you explain the mechanism led to her delayed bleeding?

 

 

Delayed bleeding after trauma is common, and is seen in as many as 42% of follow up studies...see below

 

-82.

The role of early follow-up computed tomography imaging in the management of traumatic brain injury patients with intracranial hemorrhage.

Smith JS, Chang EF, Rosenthal G, Meeker M, von Koch C, Manley GT, Holland MC.

Department of Neurological Surgery, UCSF Brain and Spinal Injury Center, San Francisco General Hospital and University of California, San Francisco School of Medicine, San Francisco, CaliforniaNNN-NN-NNNN USA.XXX@XXXXXX.XXX

Abstract

BACKGROUND: The purpose of this study was to investigate whether routine follow-up computed tomography (CT) for patients with head injury, in the absence of clinical indications, alters patient management.

METHODS: Nonpenetrating head injury patients admitted to San Francisco General Hospital during an 18-month period were reviewed. Patients not surgically treated at presentation and with a routine follow-up head CT within 24 hours were included. Surgical and nonsurgical interventions after repeat CT were assessed. Clinical and imaging parameters were correlated with progressive hemorrhagic injury (PHI) and with delayed development of surgical lesions.

RESULTS: PHI was identified in 49 (42%) of 116 patients. None of these patients required a nonoperative intervention in response to the PHI. Six of these patients developed a neurologic change concurrent with routine follow-up imaging and required operative intervention. Thus, no patient underwent an intervention in response to a worsening head CT in the absence of clinical findings. Of the six patients who developed a surgical lesion, two had increased intracranial pressure, one had a change in pupillary examination, three had worsening mental status, and one had change in the motor examination. Univariate risk factors for development of a delayed surgical lesion included 5 to 10 mm of midline shift (p = 0.001), basal cistern effacement (p = 0.01), and higher Marshall score (p = 0.01) on initial CT imaging.

CONCLUSIONS: Although PHI is common with head injury, delayed interventions in the absence of clinical indicators are uncommon. Our data suggest that early follow-up CT imaging in the setting of head trauma is not routinely indicated. We suggest that assessment, based on the severity of findings on initial brain imaging and serial clinical examinations, should guide the need for follow-up imaging in the setting of head trauma.

 

 

There are doctors in the hospital where my mom took the fall trying to tell our family that it's unusual that no abnormality was observed in CAT scan 3 hrs after the fall and bleeding occured later.

 

THat is true for it to be completely normal, but it does happen

 

I just want to understand what possibly happend in her brain between 3 hrs after the fall and 27 hrs after the fall when she entered a coma state. Do you agree that MRI would have shown abnormality 3 hrs after the fall although she couldn't have had one done due to the leads from DBS?

 

It may have shown something, but CT is pretty sensitive for blood.

 

Are there other methods might have shown abnormality than CAT scan alone 3 hrs after the fall?

 

Not really.

 

I hope that helps

 

 

Thank you for the opportunity to help you. To give me credit for my time and effort, please press the ACCEPT button for this answer. After that, I will still be glad to answer additional questions until you are satisfied.

A Positive Feedback and/or Bonus is welcomed and appreciated.

 

This answer is for information only. It cannot and should not be substituted for or the recommendation of your doctor

 

 

 

Dr. F, Board Certified MD
Category: Neurology
Satisfied Customers: 266
Experience: Neurosurgeon with more than 20 years experience in practice and teaching.
Dr. F and other Neurology Specialists are ready to help you
Customer: replied 3 years ago.

Dr. F,

 

Thank you so much for the literature. That sure helps.

 

I really appreciate your effort in answering my question.

 

Regards,

 

Bonnie

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