|
Doctors of SA: does this look like hydrocephalus to you? I have more CT slices if you want. Just curious to see what the SA goon doctors would make of an image like this. I'll fill you in on what my brother (who is a doctor) remarked about it. EDIT: More CT slices here (screen captures): http://imgur.com/mJhG1,mhYh4,l0C2V,...Gob,telD5,rm3un EDIT 2: All of the CT slices were taken at an incline plane dipping towards the poster region of my brain (the angle looks to be about 30 degrees). And for fun, a current MRI of my ventricular system: 
|
| # ? Jun 13, 2012 23:03 |
|
|
|
| # ? May 19, 2013 13:08 |
|
|
At first glance, no. But one axial slice from a CT scan in which grey-white differentiation has been replaced by some Photoshop basket weave filter is not the state of the art in this diagnosis. It looks like the extra-axial spaces are maintained and I'd like to see the temporal horns and all that, but the most helpful thing would be a prior study.
|
| # ? Jun 13, 2012 23:26 |
|
|
Yeah, I'm sorry for the crappy quality. It's a cell phone picture of a computer screen. My occipital horn (different slice) is obviously dilated. In fairness, my brother (a medical doctor) had a better image to look at. His remarks: "It looks like your brain is being smashed against your skull. You have effacement of your gyri and sulci, and almost no space between your brain and skull." When I was operated on, my intracranial pressure was 60 cm H2O -- which I understand is on the severe end of hydrocephalus. What puzzles me is why this was obvious to my brother (barely out of medical school) but was missed by a cadre of ER doctors initially.
|
| # ? Jun 13, 2012 23:41 |
|
|
I don't know how old you are, but most young people do not have a ton of space between the brain and the skull. Old people with atrophied brains have some breathing room. On this one image, you can see some sulci and some extra-axial CSF anteriorly. The brain does not in fact appear smashed against the skull. Perhaps the other images are more helpful. Regardless, this is often not an easy CT diagnosis. Did your brother make his interpretation at the time of this study or after the diagnosis was established?
|
| # ? Jun 13, 2012 23:55 |
|
|
Drag posted:I don't know how old you are, but most young people do not have a ton of space between the brain and the skull. Old people with atrophied brains have some breathing room. On this one image, you can see some sulci and some extra-axial CSF anteriorly. The brain does not in fact appear smashed against the skull. Perhaps the other images are more helpful. Regardless, this is often not an easy CT diagnosis. Did your brother make his interpretation at the time of this study or after the diagnosis was established? I'm 30. My brother recognized the symptoms of hydrocephalus, and urged me to go to the hospital. I was lucky that there was a very competent neurosurgeon at the hospital that night who recognized hydrocephalus on the scan. The ER doctors were about to discharge me before the neurosurgeon saw my CT scan. Then it was "this patient has 20 minutes to an hour to live if we do not operate now."
|
| # ? Jun 14, 2012 00:02 |
|
|
Yeah that sounds like something a neurosurgeon would say.
|
| # ? Jun 14, 2012 00:06 |
|
|
Well he was right. When he placed the shunt, cerebrospinal fluid started gushing like a fountain into the OR.
|
| # ? Jun 14, 2012 00:09 |
|
|
Did he let you keep it?
|
| # ? Jun 14, 2012 12:05 |
|
|
Kiss Kiss Bang Bang posted:Did he let you keep it? The CT disc? Yes. But I really wanted to keep the bag full of my cerebrospinal fluid. By the end of my hospitalization, nearly 3 liters had accumulated. No dice.
|
| # ? Jun 15, 2012 02:17 |
|
|
Constable Shartsky posted:Well he was right. When he placed the shunt, cerebrospinal fluid started gushing like a fountain into the OR. Yes but that doesn't imply you were imminently going to die
|
| # ? Jun 15, 2012 03:20 |
|
|
Constable Shartsky posted:But I really wanted to keep the bag full of my cerebrospinal fluid. By the end of my hospitalization, nearly 3 liters had accumulated. No dice. Darn. 3 Liters brain juice back-lit on a shelf would have been pretty awesome.
|
| # ? Jun 15, 2012 10:30 |
|
|
BEHOLD: MY CAPE posted:Yes but that doesn't imply you were imminently going to die Unless you are a neurosurgeon... no scratch that... unless you are a neurosurgeon at Johns Hopkins, I'm going to take their assessment of "60 cmH2O hydrocephalus is an imminent threat to your life" over your assessment. They probably know more than you.
|
| # ? Jun 16, 2012 02:35 |
|
|
And I'm not just trying to be an rear end here. They have had patients who died in transit to Hopkins due to severe hydrocephalus.
|
| # ? Jun 16, 2012 03:06 |
|
|
gently caress Johns Hopkins, they wait-listed me  e: Also, this Constable Shartsky posted:Unless you are a neurosurgeon... no scratch that... unless you are a neurosurgeon at Johns Hopkins, I'm going to take their assessment of "60 cmH2O hydrocephalus is an imminent threat to your life" over your assessment. They probably know more than you. Constable Shartsky posted:And I'm not just trying to be an rear end here. I think you may have hurt BMC's feelings 
|
| # ? Jun 16, 2012 05:19 |
|
|
OP, no one is really doubting that it was a serious situation. Some docs just have a flair for the dramatic statement. It's a bit incongruent that the ED docs thought you could be discharged and the surgeon thought you had 20 minutes to live, thus the reality probably lies somewhere in between. Although probably closer to the surgeon's end of the spectrum it would seem. It's sort of like having an appendectomy and being told afterward that your appendix was "just about to burst" when they managed to get it out. It sounds most excellent and can neither be proven nor disproven. Even when the path report winds up saying "normal appendix." In any case, it would seem that you were in fairly urgent need of a ventriculostomy catheter and I am glad that you received one in an expeditious manner. Did they determine the cause of your hydrocephalus?
|
| # ? Jun 16, 2012 14:13 |
|
|
Constable Shartsky posted:And I'm not just trying to be an rear end here. Then what is your point? You make this thread specifically asking for goon opinions then unceremoniously slap them down with the expert diagnosis that you already received from a doctor who actually got to examine you, see more than one slice of your CT, and turn your head into a fountain.
|
| # ? Jun 16, 2012 19:07 |
|
|
Would you mind posting a few more slices? It doesn't look very dilated to me on that slice either. And Drag's a radiologist, iirc.
|
| # ? Jun 17, 2012 00:15 |
|
|
Asstro Van posted:Then what is your point? You make this thread specifically asking for goon opinions then unceremoniously slap them down with the expert diagnosis that you already received from a doctor who actually got to examine you, see more than one slice of your CT, and turn your head into a fountain. I guess I am taking my frustrations out on internet strangers, because I saw numerous doctors who had access to more CT slices... and they concluded I was fine... and that almost killed me. The only exceptions to this were a Georgetown NS (who recognized the hydrocephalus) and my twin brother in medical school. Everyone else who has looked at the scans can obviously see the tumor (in the appropriate slice) but they don't recognize any hydro. And yet, I had ~60 cmH2O hydro, which is severe. I'm wondering why this would not be apparent on a CT. And yes, I am a little indignant at the implication that 60 cmH2O hydro is not life threatening, when a team of neurosurgeons at Hopkins said otherwise. If anything, I want to learn from this and have doctors learn from this. I could have easily died. I want to prevent that from happening to some patient in the future.
|
| # ? Jun 17, 2012 02:16 |
|
|
Drag posted:OP, no one is really doubting that it was a serious situation. Some docs just have a flair for the dramatic statement. It's a bit incongruent that the ED docs thought you could be discharged and the surgeon thought you had 20 minutes to live, thus the reality probably lies somewhere in between. Although probably closer to the surgeon's end of the spectrum it would seem. It's sort of like having an appendectomy and being told afterward that your appendix was "just about to burst" when they managed to get it out. It sounds most excellent and can neither be proven nor disproven. Even when the path report winds up saying "normal appendix." In any case, it would seem that you were in fairly urgent need of a ventriculostomy catheter and I am glad that you received one in an expeditious manner. Did they determine the cause of your hydrocephalus? Thanks. Yes, they determined that I had obstructive hydrocephalus, due to complete blockage of the foramen of monro. I had been having intermittent hydrocephalus in the past (without realizing it)... and even suggested the possibility of a tumor 6 months prior (which the doctor at the time dismissed due to lack of visual problems)... but I was very, very lucky that one particular ER doctor decided to take a CT that night and that an experienced neurosurgeon took a second look at it. If I was a religious person, I would declare the whole series of events a miracle.
|
| # ? Jun 17, 2012 02:19 |
|
|
Honestly though there's nothing surgeons love more than super dramatic statements about how much a patient needs surgery.
|
| # ? Jun 17, 2012 02:34 |
|
|
Wow, we got pimped hard in this thread.
|
| # ? Jun 17, 2012 14:41 |
|
|
Residency Evil posted:Would you mind posting a few more slices? It doesn't look very dilated to me on that slice either. Actually this is sort of relevant for all the young rad goons who will be taking call in the near future. When someone asks you to take a "quick peak" at something, decline and let them know you'll look at the whole study when you have time to do so. The quick peak is how you gently caress yourself over at 3 AM. You'll still do it anyway when you get good enough to be a little more cavalier, but it's good to avoid it when you can. squeakygeek posted:Wow, we got pimped hard in this thread.
|
| # ? Jun 17, 2012 20:29 |
|
|
And for those who are curious, the "surgery" to decompress the ventricular system is frequently performed at bedside by residents, NPs, or PAs with a fancy drill that stops cutting when you reach soft poo poo. When I was a resident they would frequently joke about their aim in neuroradiology conference. Obviously the surgery to remove the offending mass is a little bit more of a production.
|
| # ? Jun 17, 2012 20:36 |
|
|
Drag posted:And for those who are curious, the "surgery" to decompress the ventricular system is frequently performed at bedside by residents, NPs, or PAs with a fancy drill that stops cutting when you reach soft poo poo. When I was a resident they would frequently joke about their aim in neuroradiology conference. Obviously the surgery to remove the offending mass is a little bit more of a production. Yep, I had one of those. The first shunt placement (in my right ventricle) was done under full anesthesia. The second shunt placement was done bedside, with nothing more than some intravenous valium and an injection of lidocaine into my scalp before the drill came out.
|
| # ? Jun 18, 2012 02:13 |
|
|
Drag posted:And for those who are curious, the "surgery" to decompress the ventricular system is frequently performed at bedside by residents, NPs, or PAs with a fancy drill that stops cutting when you reach soft poo poo. When I was a resident they would frequently joke about their aim in neuroradiology conference. Obviously the surgery to remove the offending mass is a little bit more of a production. I did it as a 1st year medical student. CyO posted:Honestly though there's nothing surgeons love more than super dramatic statements about how much a patient needs surgery. This, especially NS
|
| # ? Jun 18, 2012 02:30 |
|
|
Based on that lovely quality one image slice, nobody would ever call hydrocephalus. And I think you're exaggerating your story quite a bit, because neurosurgeons have better things to do with their time than sit in the ER browsing random CT heads to make sure the ED docs didn't miss anything. Obviously someone (either the ED doc or radiologist) recognized something worrisome and called the neurosurgeon to take a look.
|
| # ? Jun 18, 2012 03:57 |
|
|
Dawgystyle posted:Based on that lovely quality one image slice, nobody would ever call hydrocephalus. And I think you're exaggerating your story quite a bit, because neurosurgeons have better things to do with their time than sit in the ER browsing random CT heads to make sure the ED docs didn't miss anything. Obviously someone (either the ED doc or radiologist) recognized something worrisome and called the neurosurgeon to take a look. To be fair, patients don't know this sort of thing and if the only perspective he had was that of the neurosurgeon, it's entirely possible he thinks one rock star saved his life. It's an easy mistake to make if you only get the patient view and don't realize that ''I noticed X on your CT'' really means "so a radiologist called me and told me..."
|
| # ? Jun 18, 2012 05:56 |
|
|
Constable Shartsky posted:Unless you are a neurosurgeon... no scratch that... unless you are a neurosurgeon at Johns Hopkins, I'm going to take their assessment of "60 cmH2O hydrocephalus is an imminent threat to your life" over your assessment. They probably know more than you. There is a wide, wide margin that includes "you have a life-threatening condition that requires surgery" between the extremes of "you can go home" and "you are the most precipitously ill patient in Johns Hopkins Hospital". Dawgystyle posted:Based on that lovely quality one image slice, nobody would ever call hydrocephalus. And I think you're exaggerating your story quite a bit, because neurosurgeons have better things to do with their time than sit in the ER browsing random CT heads to make sure the ED docs didn't miss anything. Obviously someone (either the ED doc or radiologist) recognized something worrisome and called the neurosurgeon to take a look. Also this; I really, really doubt that you were actually on your way out the door. NS didn't just see your CT scan by accident and I would bet with extreme confidence that neuroradiology at JHH didn't walk past an obstructing tumor, even on CT which as drag said is not the definitive study. Also I'm sure your brother is a very smart guy but retrospectoscopes are easy to use and very accurate. Regardless I am glad you got surgery and you are ok now. No hard feelings at all because I am sure it was scary and frustrating from your end of this whole experience. Did you have the tumor resected already? What's your diagnosis?
|
| # ? Jun 18, 2012 15:04 |
|
|
BEHOLD: MY CAPE posted:There is a wide, wide margin that includes "you have a life-threatening condition that requires surgery" between the extremes of "you can go home" and "you are the most precipitously ill patient in Johns Hopkins Hospital". Yeah, sorry for being a dick. To clarify, I was diagnosed at a small community hospital that happened to have a Georgetown NS on call that night. The shunt tip registered 60 cm H2O ICP upon insertion. Then I was transferred to Johns Hopkins, where they were amazed that I had survived the experience. The tumor has been resected, but it took an endoscopic attempt (which was aborted, to spare trauma to my fornix) and then a transcortical craniotomy to get it all out. I actually woke up briefly during the endoscopy... and could not communicate because of the breathing tube in my throat. It was terrifying. So the whole situation was an absolute nightmare from beginning to end... but the team at Johns Hopkins got the tumor out without doing any noticeable damage to my cognitive or physical faculties. Also, I sent the CT slices to my twin brother under the premise that they were from an anonymous colloid cyst patient that I had met through a survivors group on Facebook (there is such a group, btw). He identified hydrocephalus in the CT slices. Admittedly, he had higher resolution images, and was able to look at "the patient's" occipital and temporal horns as well. I know that I am biased, but his record demonstrates that he is an exceptional clinician. Just yesterday, a patient in his clinic was about to be discharged with a diagnosis of "sinus infection." My brother discovered that the patient actually had cancerous growths in his/her lymph nodes... after listening carefully to the patient's complaints, palpating, and ordering a CT of the lumps.
|
| # ? Jun 19, 2012 00:12 |
|
|
Constable Shartsky posted:Just yesterday, a patient in his clinic was about to be discharged with a diagnosis of "sinus infection." My brother discovered that the patient actually had cancerous growths in his/her lymph nodes... after listening carefully to the patient's complaints, palpating, and ordering a CT of the lumps. Constable Shartsky posted:In fairness, my brother (a medical doctor) had a better image to look at. His remarks: "It looks like your brain is being smashed against your skull. You have effacement of your gyri and sulci, and almost no space between your brain and skull." When I was operated on, my intracranial pressure was 60 cm H2O -- which I understand is on the severe end of hydrocephalus. What puzzles me is why this was obvious to my brother (barely out of medical school) but was missed by a cadre of ER doctors initially. Constable Shartsky posted:I guess I am taking my frustrations out on internet strangers, because I saw numerous doctors who had access to more CT slices... and they concluded I was fine... and that almost killed me. The only exceptions to this were my neurosurgeon at Hopkins (who recognized the hydrocephalus) and my twin brother in medical school. Come on, bro. I'm sympathetic to your condition but don't come in here making poo poo up trying to make us out to look stupid when you can't even get your facts straight.
|
| # ? Jun 19, 2012 06:38 |
|
|
Dawgystyle posted:Come on, bro. I'm sympathetic to your condition but don't come in here making poo poo up trying to make us out to look stupid when you can't even get your facts straight. He's a resident. Doing rounds in a hospital. Barely out of medical school. My med-training lingo is hosed, and the time period before/after my surgery sort of runs together. He was a med student before I had surgery. He is now no longer a med student. Does it make sense now?
|
| # ? Jun 19, 2012 09:56 |
|
|
Constable Shartsky posted:He's a resident. Doing rounds in a hospital. Barely out of medical school. My med-training lingo is hosed, and the time period before/after my surgery sort of runs together. He was a med student before I had surgery. He is now no longer a med student. Does it make sense now? 99% of new interns have not started yet and certainly don't have their own clinic yet like you claim. Just stop, it's easy to fool people who aren't familiar with this but I'm not one of those people.
|
| # ? Jun 19, 2012 10:22 |
|
|
Dawgystyle posted:99% of new interns have not started yet and certainly don't have their own clinic yet like you claim. Just stop, it's easy to fool people who aren't familiar with this but I'm not one of those people. I did not mean to imply that he had his own clinic. He is doing rounds in a hospital. Like I said, my medical training terminology is not precise. My surgery was over 6 months ago. There is no attempt to fool anyone here. Also, you entered this convo with "based on that lovely quality one image slice..." Don't try to pretend that I have an agenda and you do not.
|
| # ? Jun 19, 2012 10:32 |
|
|
Constable Shartsky posted:I did not mean to imply that he had his own clinic. He is doing rounds in a hospital. Like I said, my medical training terminology is not precise. My surgery was over 6 months ago. Your entire understanding of the situation is not precise. The mere fact that you think you were about to be discharged while later stating that: quote:To clarify, I was diagnosed at a small community hospital that happened to have a Georgetown NS on call that night. The shunt tip registered 60 cm H2O ICP upon insertion. Then I was transferred to Johns Hopkins, where they were amazed that I had survived the experience. ...shows me that you have grossly misunderstood the sequence of events. Neurosurgeons do not get called for patients who are "about to be discharged," especially not at a small community hospital. edit: Yes, I do have an agenda. That agenda being you coming here on your high horse trying to make other people look dumb, when it is yourself who has misunderstood the entire sequence of events. You just didn't expect anyone to actually call you out on your bullshit.
|
| # ? Jun 19, 2012 10:42 |
|
|
Dawgystyle posted:Your entire understanding of the situation is not precise. The mere fact that you think you were about to be discharged while later stating that: Kiss my loving rear end. You're the one who came in here accusing someone of outright lying. I have been completely honest. It's possible that more was going on behind the scenes than I was informed of, but that is how the situation was presented to me. The ER doctor who saw my CT scan and radiology report said, "you have a mass in your brain, but it does not appear to be a cancerous mass. It is most likely a colloid cyst. You should have the cyst monitored over time, but for now you can expect to be discharged." This is a common strategy for dealing with colloid cysts, and it's understandable that they would defer surgery (or even the possibility of surgery) to a state-of-the-art OR 30 minutes away. The ER doctor and radiologist were wrong about the urgency of the situation. They may have had doubts, but they did not express them to me. The ER doctor told me to prepare for discharge. Less than an hour later, a NS explained the urgency of the situation... to my great shock. Now, it could be that the NS completely fabricated the severity of my intracranial pressure, but I think it's more likely that you are a sanctimonious fuckstick who wants very badly for me to be full of bullshit so that anonymous internet doctors don't look ignorant.
|
| # ? Jun 19, 2012 11:01 |
|
|
Furthermore, I was awake when the NS entered a camino bolt into my left ventricle (which became blocked when the cyst migrated) and was surrounded by people who witnessed the bolt measure 40 cm H2O intracranial pressure. And that pressure remained elevated until the NS punctured the membrane between my ventricles. So I do not have serious doubts about the 60 cm H2O report.
|
| # ? Jun 19, 2012 11:09 |
|
|
By the way, the same doctor who told me that I would be discharged performed a spinal tap after the mass was discovered (pressure gradient, anyone?) to check for possible meningitis. The ER doctor explained to me that they needed to check for meningitis, because it could explain my ataxia, one-sided headache, dizziness, etc. That test came back negative. This was cited as part of the basis for my expected discharge.
|
| # ? Jun 19, 2012 11:20 |
|
|
You still fail to understand that neurosurgeons don't prance around the ED looking at CT scans. They get called if there is an issue that they need to be consulted for. The mere fact that a neurosurgeon even saw you is evidence enough that there was suspicion of something serious.
|
| # ? Jun 19, 2012 11:35 |
|
|
So the ER doc (or radiologist, or someone in the ED) called the NS in for a second opinion. Ok, fine. That makes sense. But it doesn't change the fact that this NS only sporadically does surgery at that hospital. I was lucky that he was there that night. If I had been discharged, I probably would have died that night. And I am still baffled that the ER doc and radiologist, both of who saw the "non-lovely" versions of the CT slices, completely missed my hydrocephalus and the degree of CSF blockage caused by my cyst... to the extent that the ER doc felt that it was a good idea to give me a lumbar puncture.
|
| # ? Jun 19, 2012 11:50 |
|
|
|
| # ? May 19, 2013 13:08 |
|
|
Drag posted:The brain doesn't have time to make the sort of accommodations that make the diagnosis a slam dunk in prenatal/chronic hydrocephalus. If you GIS "hydrocephalus CT," you see lots of pictures of what you expect- crazy dilated ventricles, etc. (Don't search for just hydrocephalus unless you have a thing for kids with really large heads.) Looking again at the original post, you can sort of make out the somewhat dilated right occipital horn with some volume averaging obscuring it. But some perfectly normal people have prominent occipital horns. I would guess if you could see the whole original study it would be clear that something was amiss. The mass aside, you'd probably have some periventricular decreased attenuation due to transependymal flow of CSF, in some places it would be more obvious that the extra-axial spaces were obliterated, etc. The temporal horns are particularly useful because they are rarely dilated in normal brains. I'm not surprised at all that a neurosurgeon would be more adept at picking up the findings than an ED doc. And I suppose this is the answer here. I most definitely had chronic hydrocephalus (looking back at my symptoms in the year or more prior to my surgery). My brain had adapted to chronic, intermittent, high intracranial pressure. Perhaps the radiologist was looking for something more obvious (a first instance of acute hydrocephalus would look different).
|
| # ? Jun 19, 2012 12:31 |
|
