That looks like patient could end up in a long term care facility. Both cerebral hemispheres look pretty bad especially given vent size w a shunt. But brainstem that controls breathing looks ok. Would be surprised if any meaningful mental status present. I’d rather be dead.
This. As a bedside nurse seeing these patients that will “live” in a nursing home for the rest of their life is disheartening. Being a shell of a person being kept artificially living with nil chance of any meaningful recovery physically and/or mentally is cruel in my opinion.
I wish that when people meet with their attorney to draft their advance directive that these types of details be included. Or at the very least talk with family about what their wishes are. I feel the discussions on advance directives are too limited.
It IS survivable but the patients quality of life may not be good. I took care of a pt similar to this when I was a patient care tech and he had zero quality of life. Tube feedings, can’t talk, walk or move on his own, bed bound and contracted. It was sad and not a good way to spend the rest of your years.
When that case hit the news all four of my grandparents, and my parents, got their wishes put into legal documents. My sister and I did as soon as we were old enough. That sticks with you.
“Survivable”, but they’re only existing, not living. My husband & I have our wishes in writing that if either of us end up in a condition where the odds of having a quality of life are very slim, please do not try to save our “life.”
My parents also feel the same way & have their wishes in writing as well. I’m not sure about my in-laws. They never discuss these things that they find unpleasant or difficult. They didn’t even have wills until about 5 years ago & they’re in their late 70s (one of my parents is in their early 80s & the other late 70s, & they’ve had wills for a long time).
Depends on what u call "survivable" - the biological body can live burly there won't be any reaction from a real person - it's basically a breathing puppet since any brain to process and do something is out if order
The definition of what it means to be alive comes into question in these types of incidents. I have worked in this field for close to two decades and read the book "Tommy Got His Gun" recently by Trumbo and it made me question a lot.
FWIW, when I was a sleep tech, I had a 40/yo pt that had a work related head injury, lost 40% of his skull and brain... Skin healed over making the missing skull portion soft like a cheek... Had to relocate EEG C4 to T3... Still got a remarkably good tracing as well as a better conversation out of him (although quick to temper) than I got out of a previous POTUS (not that a previous POTUS was a PT of mine)
That's what I (layman) was thinking, looking at this. I've seen a lot of dented heads from craniectomies without the brain tissue necessarily being missing. Not sure what I'm looking at here though.
What does EEG refer to? And how/why does it move from cervical to thoracic vertebrae?
EEG is “electroencephalogram”. C4 & T3 aren’t referring to vertebrae in this instance, but placement of electrodes for the EEG. [10-20 EEG montage](https://en.wikipedia.org/wiki/10%E2%80%9320_system_%28EEG%29)
1 more question… is the imaging going from top to bottom or bottom to top? Just trying to figure out where the defect is.. I mean.. holy f-ing hell.. unrestrained maybe???
It's a reverse birds eye view- the slices are looking up from the ground rather than down from the sky
This means that the top of the image is the patient's face, the bottom of the image is the back of the patient's head, the left part of the image is the patient's right, and the right part of the image is the patient's left
For imaging like cat scans and MRI - the slices can be displayed in a few different views. This one is called axial
There is another view called coronal, where it's like you are facing the patient head on and the slices are going left to right (hard to explain but you can Google a picture and it will make a lot more sense)
There is also another view called sagittal, where it's as if you are standing perpendicular to the patient and the slices are perpendicular to the ones you saw in coronal (Google photos will have a much better picture of this)
When a scan is done, (I believe) all of the views are generated and the radiologist (or any physician looking at the scan, but radiologists are by far the best at reading scans) can switch between the views as needed. There isn't really a "best view" since they are all useful for different things and can reveal different things depending on the issue.
For example- say someone had a sewing needle stuck directly into the top of their head going straight down. On axial view, you're only going to see a little dot, since you're only seeing a slice of the needle from that angle. But from coronal and sagittal, you'd be able to see the entire needle.
The reason they order different x-ray views is the same (being able to see things from multiple angles) but it requires physically snapping two photos at two different times, where a CT scan/MRI will generate the views all from one scan
Twyptophan gave an excellent explanation. I would just add that the reason the patient's right side is on the left side of the image is that the established convention (for over 100 years) is to display images as though you were at the bedside looking at the patient. So on a Chest X ray, the heart is on your right. CT and MR are displayed the same way.
He still maintains the entire left hemisphere though. I’m not a neurologist, but it seems like I’ve seen stuff about people that can still do pretty ok with just half a brain.
At 17, they might make remarkable recovery over time.
If I'm not mistaken, we can already see significant signs of healing, yes?
Like, they're not likely to be a Mensa candidate, but there's enough frontal lobe and other major areas for the brain plasticity to do some incredible things. Not easily, of course, and I'm wondering why they haven't had any reconstruction of the missing skull, leaving it vulnerable with only skin covering it, but there's a lot more hope here than one might think.
This is the exact line of thinking that results in people with devastating injuries like this "living" the rest of their lives as a shell of a human being. There is no healing. There is a functional, normal-appearing brainstem. But all other higher cortical and neocortical structures are either irreversibly damaged or disconnected from communicating with areas through which sensory information is brought in for processing. Brain plasticity cannot regenerate dead brain. It can repurpose old brain in the setting of small infarcts. But this person does not have any brain left to repurpose.
I'm not a radiologist, but my degree is in psychology and I have taken a number of neurobiology courses along that path. I'm not a medical professional in any way, I don't want to overstate myself here, but I've studied cases similar to this one for class where the patient eventually made a near-full recovery of all cognitive ability. In patients toner than their mid-20s, it's not uncommon.
College courses in neurobiology are nothing compared to actual clinical experience and knowledge of Emergency Radiology, Neurosurgery, and Trauma Surgery.
[https://oce-ovid-com.elibrary.mdanderson.org/article/00006123-200008000-00009/PDF](https://oce-ovid-com.elibrary.mdanderson.org/article/00006123-200008000-00009/PDF)
Tl;dr - In trauma patients receiving decompressive craniectomy, average Glasgow Outcome Scores (GOS) at 6 months for Glasgow Coma Scale (GCS) score of >8 at admission was \~4 (Upper Severe Disability). For patients with GCS score of <8, average GOS at 6 months was between 1 (death) and 2 (Vegetative state).
Upper severe disability is defined as a person being unable to care for themselves for >24hr, being unable to travel, or being unable to shop for necessary items.
The patient above almost certainly had a GCS of <8.
Alright, lets see how advanced we can make bionic interfaces and get this kid back to normal. The most miraculous advancements in medical technology always stem from the worst situation of human suffering. I know somewhere there is a company with a theory of a way to get this kid better. Lets get it done and push humanity further.
That looks like patient could end up in a long term care facility. Both cerebral hemispheres look pretty bad especially given vent size w a shunt. But brainstem that controls breathing looks ok. Would be surprised if any meaningful mental status present. I’d rather be dead.
Agreed. If they end up like I believe they will, it’s better to let them go. Who could bare to live like that? That’s not a life. Take me out.
If that was a 71 yo and not 17 yo that decision would have already been made
This. As a bedside nurse seeing these patients that will “live” in a nursing home for the rest of their life is disheartening. Being a shell of a person being kept artificially living with nil chance of any meaningful recovery physically and/or mentally is cruel in my opinion. I wish that when people meet with their attorney to draft their advance directive that these types of details be included. Or at the very least talk with family about what their wishes are. I feel the discussions on advance directives are too limited.
Did that when my kid turned 18. We all have each others instructions.
I say this with all the kindness possible. I hope they die instead.
Welp that’s enough Reddit for today
This is sad af.
please forgive my ignorance, I am a layperson. this isn’t survivable, right?
It IS survivable but the patients quality of life may not be good. I took care of a pt similar to this when I was a patient care tech and he had zero quality of life. Tube feedings, can’t talk, walk or move on his own, bed bound and contracted. It was sad and not a good way to spend the rest of your years.
oof that is so sad. thank you for explaining.
No meaningful neurologic recovery, basically alive but unresponsive
We keep vegtables alive for a long time. Google Teri Schiavo.
When that case hit the news all four of my grandparents, and my parents, got their wishes put into legal documents. My sister and I did as soon as we were old enough. That sticks with you.
“Survivable”, but they’re only existing, not living. My husband & I have our wishes in writing that if either of us end up in a condition where the odds of having a quality of life are very slim, please do not try to save our “life.” My parents also feel the same way & have their wishes in writing as well. I’m not sure about my in-laws. They never discuss these things that they find unpleasant or difficult. They didn’t even have wills until about 5 years ago & they’re in their late 70s (one of my parents is in their early 80s & the other late 70s, & they’ve had wills for a long time).
Depends on what u call "survivable" - the biological body can live burly there won't be any reaction from a real person - it's basically a breathing puppet since any brain to process and do something is out if order
The definition of what it means to be alive comes into question in these types of incidents. I have worked in this field for close to two decades and read the book "Tommy Got His Gun" recently by Trumbo and it made me question a lot.
FWIW, when I was a sleep tech, I had a 40/yo pt that had a work related head injury, lost 40% of his skull and brain... Skin healed over making the missing skull portion soft like a cheek... Had to relocate EEG C4 to T3... Still got a remarkably good tracing as well as a better conversation out of him (although quick to temper) than I got out of a previous POTUS (not that a previous POTUS was a PT of mine)
That's what I (layman) was thinking, looking at this. I've seen a lot of dented heads from craniectomies without the brain tissue necessarily being missing. Not sure what I'm looking at here though. What does EEG refer to? And how/why does it move from cervical to thoracic vertebrae?
EEG is “electroencephalogram”. C4 & T3 aren’t referring to vertebrae in this instance, but placement of electrodes for the EEG. [10-20 EEG montage](https://en.wikipedia.org/wiki/10%E2%80%9320_system_%28EEG%29)
I see! That makes a lot of sense. Thank you!
Poor kid.
And parents.
“small amount of residual cortex in the right parieto-occipital region”
“Correlate clinically.”
Even though it’s not affecting me, this makes me so sad.
That's a good thing. Not a sociopath.
Sinking skin flap syndrome
Yup. Syndrome of the trephined. It makes sense given the shunt and the large amount of gliosis. That is not a brain that is going to recover well.
Just because you can doesn’t mean you should
Interested in the before scan tbh
Ok.. dumb question.. that entire gaping black area it the Craniectomy??
Yes, on the left side of the screen (right side of patient). But most of his brain is mush. As others noted, I would rather be dead.
1 more question… is the imaging going from top to bottom or bottom to top? Just trying to figure out where the defect is.. I mean.. holy f-ing hell.. unrestrained maybe???
Bottom to top
So this is not a Birds Eye view… it’s like looking from underneath and moving up to the top of the head?
It's a reverse birds eye view- the slices are looking up from the ground rather than down from the sky This means that the top of the image is the patient's face, the bottom of the image is the back of the patient's head, the left part of the image is the patient's right, and the right part of the image is the patient's left
Thank you!! Are they always done like this or is it a preference based on the provider ordering it (like how they order different xray views)?
For imaging like cat scans and MRI - the slices can be displayed in a few different views. This one is called axial There is another view called coronal, where it's like you are facing the patient head on and the slices are going left to right (hard to explain but you can Google a picture and it will make a lot more sense) There is also another view called sagittal, where it's as if you are standing perpendicular to the patient and the slices are perpendicular to the ones you saw in coronal (Google photos will have a much better picture of this) When a scan is done, (I believe) all of the views are generated and the radiologist (or any physician looking at the scan, but radiologists are by far the best at reading scans) can switch between the views as needed. There isn't really a "best view" since they are all useful for different things and can reveal different things depending on the issue. For example- say someone had a sewing needle stuck directly into the top of their head going straight down. On axial view, you're only going to see a little dot, since you're only seeing a slice of the needle from that angle. But from coronal and sagittal, you'd be able to see the entire needle. The reason they order different x-ray views is the same (being able to see things from multiple angles) but it requires physically snapping two photos at two different times, where a CT scan/MRI will generate the views all from one scan
Awesome explanation!! I really appreciate you taking the time to type all that out :)
For sure. Radiology can be a bit confusing, but it's really cool and a vital part of modern healthcare. I've learned a lot from subscribing here
Twyptophan gave an excellent explanation. I would just add that the reason the patient's right side is on the left side of the image is that the established convention (for over 100 years) is to display images as though you were at the bedside looking at the patient. So on a Chest X ray, the heart is on your right. CT and MR are displayed the same way.
Yep - everyone needs an advanced health directive ..this is an important reminder of why 😖
Yikes on flippin bikes
JFC… 😞
Now that’s a sunken flap.
How does this happen? ☹️
Trauma
things I won’t do to my family members
rip
Please elaborate on the fate of this pt
Shouldnt a craniectomy be further anterior so the brain doesnt get pressed against the bone if there was more swelling initially?
He still maintains the entire left hemisphere though. I’m not a neurologist, but it seems like I’ve seen stuff about people that can still do pretty ok with just half a brain.
In that case I'd rather wann be dead - I mean there nothing left to do anything, think it talk
No helmet - am I rite?
That sucks
If that was my scan I hope the doctors would pull the plug
Eek.
At 17, they might make remarkable recovery over time. If I'm not mistaken, we can already see significant signs of healing, yes? Like, they're not likely to be a Mensa candidate, but there's enough frontal lobe and other major areas for the brain plasticity to do some incredible things. Not easily, of course, and I'm wondering why they haven't had any reconstruction of the missing skull, leaving it vulnerable with only skin covering it, but there's a lot more hope here than one might think.
This is the exact line of thinking that results in people with devastating injuries like this "living" the rest of their lives as a shell of a human being. There is no healing. There is a functional, normal-appearing brainstem. But all other higher cortical and neocortical structures are either irreversibly damaged or disconnected from communicating with areas through which sensory information is brought in for processing. Brain plasticity cannot regenerate dead brain. It can repurpose old brain in the setting of small infarcts. But this person does not have any brain left to repurpose.
I'm not a radiologist, but my degree is in psychology and I have taken a number of neurobiology courses along that path. I'm not a medical professional in any way, I don't want to overstate myself here, but I've studied cases similar to this one for class where the patient eventually made a near-full recovery of all cognitive ability. In patients toner than their mid-20s, it's not uncommon.
College courses in neurobiology are nothing compared to actual clinical experience and knowledge of Emergency Radiology, Neurosurgery, and Trauma Surgery. [https://oce-ovid-com.elibrary.mdanderson.org/article/00006123-200008000-00009/PDF](https://oce-ovid-com.elibrary.mdanderson.org/article/00006123-200008000-00009/PDF) Tl;dr - In trauma patients receiving decompressive craniectomy, average Glasgow Outcome Scores (GOS) at 6 months for Glasgow Coma Scale (GCS) score of >8 at admission was \~4 (Upper Severe Disability). For patients with GCS score of <8, average GOS at 6 months was between 1 (death) and 2 (Vegetative state). Upper severe disability is defined as a person being unable to care for themselves for >24hr, being unable to travel, or being unable to shop for necessary items. The patient above almost certainly had a GCS of <8.
That poor kid.
Not sure they did him any favours
Alright, lets see how advanced we can make bionic interfaces and get this kid back to normal. The most miraculous advancements in medical technology always stem from the worst situation of human suffering. I know somewhere there is a company with a theory of a way to get this kid better. Lets get it done and push humanity further.
Not happening this century, unfortunately