Hi Bonnie, I am a neurosurgeon and will try to answer your question
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
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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)?
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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.
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
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
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?
Thank you so much for the literature. That sure helps.
I really appreciate your effort in answering my question.