Please forgive the length of this post, I want to make sure I give you all of the information. Also, my wife is a neuro nurse, so I know just enough to be dangerous.

4 weeks ago, my friend complained to his wife that he thought he had the flu. Over the next two days, he got worse and complained of a headache. The next day, his wife found him collapsed and took him to the hospital. They immediately suspected spinal meningitis and began treating with antibiotics. After an hour, he was able to talk and in interviewing him, they discovered he had been taking antibiotics for a tooth infection and they determined he had an abscess that went from his tooth to his brain. They performed CAT scans and MRI’s over the next four weeks while treating with antibiotics and meds to reduce swelling in his brain.

He improved, though he had problems with speech, memory, etc. However, through all of the tests, the abscess never changed size. Eventually, after nearly 3 weeks, he was moved from intensive care to a regular unit, still being treated with antibiotics but not the med for brain swelling. While on the other unit, he developed an infection from his pic line and was taken back to ICU. Differrent antibiotics were used and the brain swelling med was reinstated and he quickly improved to where he had been.

The doctor, after another MRI, stated that the ventricule was filling with fluid and needed drained. He recommended surgically inserting a catheter to the ventricule for drainage.

The doctor stated it wold take about 2 hours to perform the surgery. After 3 hours, he came out and stated there was a problem. He stated that as soon as they drilled the hole in his skull, they ruptured a blood vessell on the outside of his brain. They eventually stopped the bleed, but the blood clotted and there was a huge clot they neededx to remove. After nearly 7 hours, he was taken back to ICU in grave condition. At first, he responded to pain and light stimuli, but throughout the night his pupils have ceased reacting to light. This morning, they ran a CAT scan and the doctor told us that his brain stem has filled with blood.

My questions:

Can the blood clot that quickly during surgery, especially considering he had been on blood thinners up until a couple of days before surgery?

Shouldn’t the MRI used to map the surgery have seen the blood vessel?

If the ruptured blood vessel was on the outside wall of his brain, how could the brain stem fill with blood?

Is it possible it was a misdiagnosis? Do blood clots and abscesses look similar in an MRI and CAT scan (especially since they were looking for an abscess)? Could he had had a small aneurysm which created the clot, and then when they went in, it opened it back up?

Please answer these questions and help us to understand what has happened.

Thank you.

Dr.Sinuhe Answers:

Thank you for your question. As you are not immediate family of the patient and I’m not the attending neurosurgeon, I’m sure we’re missing a lot of information here. It is also possible that you have misunderstood something. Therefore, I cannot know what has happened and you need to understand that I am speaking in general terms here since I don’t have all the necessary information.

Your friend’s wife should feel free to talk to the neurosurgeons about her possible concerns - they will be able to explain what happened. Please understand that it is up to her whether she wants to share the details with you. Moreover, if you’re suspecting that things didn’t go as planned, you’re probably not making her feel any better by adding to her concerns.

Now, having said all that, I’ll try to answer your questions:

The story is pretty much normal until the placement of the ventricle catheter. Even form that point on, nothing that couldn’t normally happen, happened.

The reason for need for drainage may be either that the infection disturbed the normal fluid circulation of his brain (we all are producing about two cups of cerebrospinal fluid inside our brain every day and it needs to drain properly) or that the infection had spread into the ventricle system and needed drainage. The latter is the worse option since this condition has high mortality - with or without the ventricle catheter.

Yes, the blood can clot that quickly.

The MRI probably would not show the vessel in this type of case. Usually, MRI is not used for navigation in this type of surgery. Basically, the operation is very simple. It does, however, include a small risk for rupturing a vessel, as the surgeon does not see where the tip of the catheter is going inside the brain. The risk is clearly smaller than not treating the patient in the first place, however. The risk is higher if a patient is on blood thinners and if there is an infection inside the ventricle.

I assume that the ruptured vessel was inside the brain, not on the outside wall. This is because if it were on the outside, it should be relatively simple to point out and repair the damage during the operation (but not always, though).

No matter where the blood/clot is inside your skull, it will - if big enough - increase the pressure inside your skull and eventually damage the otherwise healthy areas. One area prone to damage because of high pressure is the brain stem. After pressure damage, it often becomes hemorrhagic. If it is “filled with blood” as you say, it means the degree of damage is high and that the patient most likely will not survive.

I don’t think we need to assume this was a misdiagnosis - just that your friend had a severe illness and while treating it something bad happened. Unfortunately, this type of thing happens frequently in neurosurgery - the diseases as well as treatments have dangers and the target is very, very fragile. But being a neurosurgeon, I’m confident that his doctors did their best and that without treatment your friend’s outcome would have been unfavorable.

Hope this helps.

Dr Sinuhe

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