A Forensic Analyst, Dr. Gerald Tedesco, raises similar questions to mine about Terri’s autopsy report in an article at the North Country Gazette. (Hat Tip Terri’s Fight) Questions about:

• Sampling (I discuss and link to materials about that here)




• The relatively intact frontal lobes (I discuss here, here, here, and here.

He also discusses the possible events that could have caused Terri’s condition. He talks about the mechanisms of injury:

Mechanisms of injury: These can occur by intention or accidentally during a struggle to restrain another person by applying chokeholds, headlocks, Traumatic compression (when a larger individual uses his body weight to restrain a smaller person on the floor for example – restricting chest expansion and respiration. Remember, there was evidence Terri did sustain posterior rib fractures, and sexual edge play (erotic asphyxia).

I talked about non-traumatic asphyxia here.

• Also, Dr. Tedesco talks about the role dehydration plays in brain shrinkage:

Drs. Thogmartin and Nelson claimed Terri’s brain weighed 615 grams (about 50% weight). But, Dr. Thogmartin also stated this was the worst case of dehydration he had ever seen. Her body cavities were completely dry. I would bet that some of the loss in brain weight was due to the dehydration (the brain is 75% water). This is supported by research studies conducted on brain volume and dehydration.

“An article on one such study was published by the American Academy of Neurology. This is a brief excerpt: “Dehydration confounds the assessment of brain atrophy” by T. Duning, MD, S. Kloska, MD, O. Steinsträter, PhD, H. Kugel, PhD, W. Heindel, MD and S. Knecht, MD. From the Departments of Neurology and Clinical Radiology, University of Münster, Germany. Computerized brain volumetry has potential value for diagnosis and the follow-up evaluation of degenerative disorders. A potential pitfall of this method is the extent of physiologic variations in brain volume. The authors show that dehydration and rehydration can significantly change brain volume: lack of fluid intake for 16 hours decreased brain volume by 0.55% (SD, ±0.69), and after rehydration total cerebral volume increased by 0.72% (SD, ±0.21).”

He is citing to the same article I cited to here. (scroll down to the bottom)

Like I said, I had many of the same kinds of questions that Dr. Tedesco addresses in the article. I’m not a doctor. If I can read an autopsy report word for word and look things up on the internet and figure out questions—why couldn’t the journalists covering the story of the autopsy?

Furthermore, the facts Dr. Tedesco raises about what it takes to diagnose PVS are very germaine to what is going on in so-called “futile care” cases here in Texas. Like this one that I am working on.

Human Events Online publishes a great commentary on the autopsy by Dr. Sherri Eros who is a blogger. She is appalled by the media’s irresponsible reporting and by the representations made by the Medical Examiners about PVS in light of the disclaimer in the report that PVS cannot be diagnosed by autopsy. To wit:

As Thogmartin and Nelson clearly state in the written Autopsy Report, it is impossible to confirm a diagnosis of PVS postmortem—on the basis of an their own autopsy. As explained above, to say that the autopsy is “consistent with” persistent vegetative state is utterly devoid of meaning because it is just as true that the autopsy is “consistent with” Terri’s having been in a conscious state of one level or another.

Therefore it was extremely misleading, and even medically reprehensible, for either ME to have stated to the press that the autopsy results are either “consistent with” or “not inconsistent with” a PVS diagnosis, without in every instance where the topic of PVS arose, emphasizing and repeatedly cautioning the press in the strongest possible terms that such a statement must not be misinterpreted as lending support to the PVS diagnosis. This caution appears not to have been given at the news conference.

She also corrects me being quoted in WND when I suggested regarding the relative preservation of the frontal and temporal: “What this tells us is that her cortex retained function.” According to Dr. Eros : As noted above, such determinations are entirely outside the scope of postmortem data and can be made only through examination of the living patient.

This is fair and what I should have said is that it the autopsy does not rule out that the cortex retained function. Lesson learned.

This is an article well worth reading.

As I wrote about here, Dr. William Hammesfahr said the following:

Dr. Maxfield and myself both emphasized that she was a woman trapped in her body, similar to a child with cerebral palsy, and that was born out by the autopsy, showing greater injury in the motor and visual centers of the brain. Obviously, the pathologists comments that she could not see were not borne out by reality, and thus his assessment must represent sampling error. The videotapes clearly showed her seeing, and even Dr. Cranfoed, for the husband, commented to her that, when she could see the balloon, she could follow it with her eyes as per his request. (emphasis added)

Here is an article that explains sampling errors. If you google sampling errors autopsy brain—or similar searches you will find articles talking about it in the field of pathology. You will see references about size of tissue samples, number of samples and other issues.

As I wrote here, although the autopsy report refers to objective findings—the report is subjective in the sense that the neuropathologist gives opinions about the findings—and in fact—is describing what he found on microscopic slides with a certain degree of subjectivity because the description is based on his perception.

The report, therefore, cannot put all issues to rest because of its subjective elements and because that is not how such reports are treated in science or in court. Every day the opinion of a medical expert or medical examiner is being tested in a courtroom somewhere in this country.

For years, I deposed physicians in personal injury cases. I deposed a few medical examiners in wrongful death cases about cause of death as well. In some cases, I hired experts to evaluate the opinions of those I was about to depose.

I would do several things to prepare for those depositions. I would read the medical reports of the deponent. I would research authoritative sources both to understand what the reports said and to see if there was information that supported or conflicted with the opinions of the deponent.

I would subpoena all of the working notes, laboratory reports, documents on the protocols used and all information on samples that were tested. I would study all the steps the physician was supposed to take in order to make a proper diagnoses. I would get input from my expert as to weaknesses demonstrated in the report and the supporting documentation or as reflected in the procedures used.

I learned long ago that just because somebody with a medical degree said it was so—didn’t make it so.

In the case of Terri’s autopsy, we have not seen any of the back up notes or data upon which it is based. Granted, much of the procedure used is detailed. We know that a total of 65 glass microscopic slides were examined. We don’t know what the individual findings were for each and every slide because we don’t have the notes.

We don’t know how many slides were taken from the cerebral cortex and thalamus to be examined. We don’t know the size of the sample contained by each slide.

We see language like this: “There was laminar necrosis involving the middle cortical lamina, in most cortical sections examined microscopically, but this finding was patchy.” What was the sample size (the overall number of slides)? What percentage was “most”? 51% ? Something larger? We don’t know.

When Nelson addressed the part of the brain affecting vision—the lateral geniculate nucleas—what number of samples did he examine? How much material was on each slide? What is the margin for error and what is more definitive on the issue—the particular tissue examined or clinical diagnosis?

There is much to be explored and evaluated about this report, the procedures used and the conclusions. It appears that the MSM is satisfied and has moved on to other subjects. Don’t believe that the MSM has covered this autopsy in a full and satisfactory manner. It hasn’t.

I will be a guest on Mychal Massie’s radio show, Straight Talk tomorrow (Tuesday, June 21) at about 1:20 pm ET to talk about the Terri Schiavo autopsy report and the questions I have.

You can listen to it at this site.

One of the neurologists, Dr. William Hammesfahr who examined Terri weighs in on the autopsy report addressing some of the same things about which I have raised questions: (HT Empire Journal)

The noted neurologist said he had had a chance to look at neuropathologist Dr. Stephen Nelson’s analysis of the brain tissue. Nelson of Winter Haven is the District 10 medical examiner “The autopsy results confirmed my opinion and Dr. William Maxfield’s opinions, that the frontal areas of the brains, the areas that deal with awareness and cognition were relatively intact. To use Dr. Nelson’s words, “relatively preserved.” In fact, the relay areas from the frontal and front temporal regions of the brain, to the spinal cord and the brain stem, by way of the basal ganglia, were preserved, thus the evident responses which she was able to express to her family and to the clinicians seeing her or viewing her videotape. The Spect scan confirmed these areas were functional and not scar tissue, and that was apparently also confirmed on Dr. Nelson’s review of the slides. Dr. Maxfield’s estimates of retained brain weight were apparently accurate, although there may have been some loss of brain weight due to the last two weeks of dehydration”.

In my last post, I mentioned blogger Dr. Rangel who has different thoughts and one of my commenters Brain Doc. Both make contrary aguments worth reading. I have two thoughts about this.

One, why is the press not asking hard questions about this? I simply don’t understand the lack of professional curiosity on its part.

Two, it is apparent that physicians can’t even agree on the autopsy results or the clinical diagnosis. Terri was not a machine after all. When a machine has missing parts that can’t be replaced—it’s ultimately and finally broken and unusable. With a machine—one can be sure about just how broken it is—not so with a human.

Judge Greer was using the same kind of legal judgment that a judge would use when faced with repeated requests for looking at other testimony or diagnostic testing a machine that is the subject of a products liability suit and is alleged to be defective. Of course, at some point a judge would say no in the case of a machine—enough is enough. And, at some point a Judge would stop everything and make a final decision about the allegedly defective machine.

This reasoning was inappropriate in the case of Terri. We are not machines.

Update: Pro-life blogs has this story as well and quotes the Doctor as saying:

Dr. Maxfield and myself both emphasized that she was a woman trapped in her body, similar to a child with cerebral palsy, and that was born out by the autopsy, showing greater injury in the motor and visual centers of the brain. Obviously, the pathologists comments that she could not see were not borne out by reality, and thus his assessment must represent sampling error. The videotapes clearly showed her seeing, and even Dr. Cranfoed, for the husband, commented to her that, when she could see the balloon, she could follow it with her eyes as per his request.

The sampling issue is interesting and I intend to address it later.

Okay, more questions. A commentor at one of my posts is a brain doctor. He has raised the issue of the fact that the autopsy report points out that the “larger pyramidal neurons were globally absent” in the cerebral cortex. A doctor blogger points out in his comments that the “relative preservation” of the frontal and temporal lobe means preservation compared to the massive damage elsewhere—but that those locations were still severely damaged.

The report says that the granular neurons of the cerebral cortex were relatively preserved—though damaged since the report speaks to global damage. I know that we have to accept that Terri had severe brain damage. I think that we still have to ask whether or not these findings unequivocably rule out any level of consciousness.

Granted, I do not believe that PVS justifies withdrawal of nutrients and hydration—so I wouldn’t concede that what was done to Terri was right under any circumstances. Given that, I do not want to just concede that because some doctors say so—that the autopsy unequivocably and with certainty shows that she had absolutely no level of consciousness whatsoever—without asking every question possible.

It is certain that she had a badly damaged brain. Yet the part of the brain where IQ and personality reside—though badly damaged—is not as damaged as the rest.

• Does this, without doubt prove that she was 100% unconscious? What were the neurons that she had left doing?
• I found an article about THE SINGLE-NEURON THEORY OF CONSCIOUSNESS. Do some doctors and researchers think that if there is a neuron there is a chance of consciousness?
• If the pyramidal neurons are gone, do the granular neurons (stellate cells) fill in and support consciousness in any way?
• Fr. Johansen spoke to other neurologists who stated that loss of tissue found upon autopsy cannot diagnose PVS or clincial status—does that mean that as long as she had tissue that was intact to a degree and some neurons—she may have had some degree of consciousness?

Brain Doc believes that: The anterior and medial thalamus had less than the massive damage reported in the cortex and basal ganglia. This is buried in the report of the microscopic H+E slides. In simple terms, it(the antero-medial thalamus) coordinates emotion/ drives by communicating to the cortex, but only if activated by the rest of the thalamus,which I doubt it could be. It is interesting for me, but it changes little.

I found this article about the thalamus which suggests that there are competing theories about its role in consciousness. So, another question—is there disagreement in the medical community about its role and how it works?

Dr. Rangel at RangelMD answered some questions in his comments. The report talks about the LARGER pyramidal neurons being globally absent. I asked does that mean there were other pyramidal neurons present? He believes that the term LARGER was used to distinguish between the granular—or stellate—neurons (cells) and the pyramidal. So I thought there was no such thing as larger and smaller pyramidal neurons. Then I find this source that talks about larger and and smaller pyramidal neurons.

So, another question: If there were smaller pyramidal cells present—what does that mean in terms of the possibility of consciousness? And, if there were smaller pyramidal’s present were they interconnecting with the granular or stellate neurons? And could this yield some degree of consciousness?

When people say that the autopsy proves that she was PVS or unconscious, I have to question that. To me, that would be an opinion based on some degree of subjectivity.

No doubt there are objective findings recounted in the report. But the meaning of those findings is based on the expert’s subjective opinion. Even his observations of the brain at the microscopic level involve some degree of subjectivity because he is perceiving the results and then reporting based on his opinion of what the slides show. So, there is an element of the subjective contained in every medical report.

I believe that only God knows with certainty whether or not Terri was conscious. In the meantime, I think that it is appropriate for us to question and argue about what the findings recounted in the autopsy really mean.

Update:

Dr. Rangel said this in his post:

The optic nerves were atrophied and the visual centers of the brain, which interpret signals from the eyes and optic nerves and allow for conscious awareness of visual stimuli were completely destroyed.

He believes that there was complete destruction because the report said that the most damage was done to the occipital region.

Obviously, she was completely blind or visually impaired to a severe degree. But—does that rule out all consciousness? Here is a medical article that says:

Many patients who are misdiagnosed as being in the vegetative state are blind or have severe visual handicap; thus lack of eye blink to threat or absence of visual tracking are not reliable signs for diagnosing the vegetative state.

The article states that PVS is a clinical diagnosis requiring many steps. Did Cranford take all of the steps?

I want to sum up some of the questions that I believe should be asked based on the topics I have discussed here, here, here and here.

1. With regard to the extent of the brain damage:

a. Two parts of the brain appear to be important here, the cortex and the thalamus.

b. The cortex appears to be relatively well-preserved in the frontal and temporal lobes. What does that mean?

c. The frontal lobe is where IQ and personality reside.

d. The neuropathologist indicates that the thalamus appears relatively preserved, but on
microscopic examination has some damage that is not quantified by the pathologist.

e. The role of the thalamus is now considered more important to consciousness than
thought previously because of the findings made upon examination of Karen Anne Quinlan’s
brain.

f. The neuropathologist compares the weights of Terri’s and Karen’s brains—but notably
does not mention how the brain damage compares though Terri has some intact cortex (as
did Quinlan) and some damage to the thalamus.

g. The greatest damage to Terri’s brain was in the back—essentially the part that controls
motor skills and physical ability.

h. Terri was dehydrated to death, Karen was not.

Thus:

1. Given the significance of the thalamus to consciousness and the fact that Quinlan’s main problem was damage to that part of the brain—why did the neuropathologist not see fit to make a comparison of the two thalumuses? Could it be because Terri’s thalamus was not as damaged and had viable tissue?
2. If Terri had viable cortex and viable thalamus—is it not medically possible that she was conscious of everything that was being done to her?
3. Is the brain weight comparison between Terri and Karen really apt in light of the fact that Terri was dehydrated for weeks? Emcee has good information on that point.
4. What is more important, brain weight or brain architecture? If Karen Quinlan had no viable thalamus tissue and Terri did—isn’t that more significant?
5. If Terri’s and Karen’s thalamus damage was similar in degree, wouldn’t the neuropathologist have mentioned that as well as brain weight?

With regard to the argument by the neuropathologist supporting the judge’s decision not to allow an MRI or PET scan.

1. Did he check with the manufacturer to determine whether Terri’s implants contraindicated an MRI?
2. Why did he not disclose in the report that his authoritative source on this point says that it is only “some” implants that contraindicate MRI’s?
3. Who asked him to address that issue. If it no one did, why did he address it?

Finally, on the brain:

1. If Terri’s implants were not of the type that contraindicated an MRI or PET scan (or adequate precautions could be taken to prevent complications), and given that Terri had viable cortex and viable thalamus and given that PVS cannot be diagnosed by autopsy—shouldn’t those tests have been administered? Wouldn’t they have more accurately revealed her true cognitive state than an autopsy performed after she was dead?

Update: I want to add something based on Captain Ed’s post at Captain’s Quarter’s wherein he paraphrases the Medical Examiner saying: With her vision center destroyed, she had cortical blindness. In the opinion of the coroner after examining the brain, Terri’s condition would never have improved.

The brain autopsy says this about the vision centers on page 4 of Nelson’s report: The lateral geniculate nucleus (visual) demonstrated transneuronal degeneration with gliosis, while the medial geniculate nucleas (auditory) was relatively preserved.

First, this does not say that she is totally blind—it says she has degeneration with gliosis—it does not quantify exactly how much—or at least the amount is not clear from the narrative in the report. (Update: Dr. Rangel at RangelMD belives that the report indicates that it was destroyed—see his comments in the comments section) Second, gliosis is: an excess of astroglia in damaged areas of the central nervous system; see also astrocytosis. Third, dehydration can cause an increase of astrocytosis according to a study done on mice. Read the article. Even after rehydration the increase continued. Recall that Terri underwent dehydration twice.

Further, even though you cannot replace neurons—you can retrain the ones left. Is it not possible that when the neuropathologist says she couldn’t have improved—he is talking only about brain architecture? Rehabilitation does not change brain architecture—it merely retrains what one has left. This report does not prove that Terri could not have regained some functions—especially given the relatively good state of her frontal lobes.(Update: It has been made clear to me by reading Dr. Rangel , that the frontal lobes were severely damaged—though not has much as other areas—Thus, to rephrase: Does this report truly and completely rule out any possibility of improvement in function?) And, I would ask whether or not removing the thalamus implants might have improved the communication between the frontal lobes and the back of the brain where motor skills and physical ability are found—thus enabling more physical function. Someone should ask that question.

More questions for inquiring minds later.

How valid is the comparison made between the brain of Karen Anne Quinlan and Terri Schiavo? The neuropathologist makes the comparison in terms of weight. I’ve already discussed the effects of dehydration here.

But are they comparable in terms of brain damage? I think that an arguement can be made that they are not. It all boils down to the Thalamus. The greatest damage to Quinlan’s brain was to the thalamus (she had some intact cortex). The conclusion was made that:
The findings in Karen Quinlan’s brain suggested that the thalamus played a more crucial role in consciousness and awareness than was previously thought.

What about Terri’s thalamus? On page 4 of the neuropathologist’s report it says:

In the thalamus, the most medial portions were relatively preserved (from the frontal cortex).

When the thalamus was examined microscopically, damage was definitely detected—though not as much damage as was done to the basal ganglia. The bottom line is that Terri’s thalamus suffered damage to a degree—but there is no indication from the neuropathologist that it was damage as severe as Quinlan’s. The pathologist had the opportunity to say that Terri’s thalamus was as damaged as Quinlan’s when he compared the weight of the brain—but didn’t. He just compared the weight.

Does weight really matter as much as the nature of the damage?


The thalamus is like mission control for your body.

I have been asked to be a guest on WND’s Radioactive with Joseph Farah (his radio show) to talk about the Terri Schiavo Autopsy report. You can listen here.

If this really happens, I should be on soon after 3:30 pm Central Time.

Update:

Well, I was on. I think I did okay.

I just spoke to an R.N. whose husband has frontal lobe impairment. Her husband walks, talks and functions. She looked at the autopsy report last night and and noted one of the findings that I wrote about here: “The frontal temporal and temporal poles and insular-cortex demonstrated relative preservation”What this tells us is that her cortex may have retained some function and that her brain was more normal (correction: though badly damaged) in the area that controls higher-level thinking (the IQ part of the brain, people!). Can they really tell us the cortex had absolutely no viable function as relates to consciousness given this?

That part of the brain is where:

Frontal lobes have been found to play a part in impulse control, judgement, language, memory, motor function, problem solving, sexual behavior, socialization and spontaneity. Frontal lobes assist in planning, coordinating, controlling and executing behavior. People who have damaged frontal lobes may experience problems with these aspects of cognitive function, being at times impulsive; impaired in their ability to plan and execute complex sequences of actions; perhaps persisting with one course of action or pattern of behaviour when a change would be appropriate (perseveration).

Is it possible that she remained cognizant of sounds and other things without being able to communicate? According to my nurse friend, her husband’s frontal lobe impairment might be worse than Terri’s was. (Update: According to some of my medical commentators—this is in all probability not the case because of the missing larger pyramidal neurons in Terri’s brain)

If the nurse is correct, we should all consider the possibility that Terri was aware of everything being done to her at some diminished level—yet could do little to make people aware that she was there!

Also, go look at this part of the autopsy report on page 5 of the report about possible causes of her original injury (not the neuropathologist’s report):

f. What other etiolologies are possible?

Subtle trauma related to commotio cordis or nontraumatic asphyxia is also possible, but no evidence of this exists….

Commotio cordis is a good old hit to the solar plexis:

What Is Commotio Cordis?

Commotio Cordis is a syndrome that results from a blunt impact to the chest which leads to cardiac arrest. It is a poorly recognized and underreported event that happens to healthy young athletes as a result of a low-energy, non-penetrating blow to the chest. Commotio Cordis does not result solely from the force of a blow. It is largely the result of the exquisite timing of the blow during a narrow window within the repolarization phase of the cardiac cycle, 15 to 30 msec prior to the peak of the Twave.

If that happened—is it possible that no evidence would exist after the passage of time, and/or any evidence would have been masked by CPR efforts undertaken after she was found in extremis?

And what about nontraumatic asphyxia? How much evidence would a pillow or big hand held over the face by a huge man leave that could not also be explained away by the fact that she was found face down on the floor?

This autopsy report does not rule out the above possibilities. Conversely, it finds no evidence to support an event caused by an eating disorder.

No person involved in rushing her to death is exonerated by this report.

Update so that I can trackback to Michelle Malkin. Michelle—look at the descriptions of what is actually damaged. Then go here to here and here to see possible holes in the MSM’s claims that the report means that Schiavo had no consciousness.

Michelle says:

You do not need a medical examiner’s license to see that the report raises many more questions than it answers, though from the (once again) misleading media coverage, we are led to believe that the matters of Terri’s life and murder are resolved. They are not.

Michelle is right.

The issue I discussed last night in this post about the neuropathologist’s decision to throw a paragraph into the report about the decision not to allow an MRI is still bothering me. The more I think about it, the more it seems like something I would have an expert witness write about in order to defend my client against some allegation. It doesn’t belong in a report that is supposed to be objective.

It is not germaine to the purpose of an autopsy. So why did he write it? Remember all the talk that Terri’s cerebral cortex was gone and replaced by a “bag of water” or “mush”? The report, though showing severe damage, does not seem to bear that out. To be sure, the cortex had necrosis, but the report says such things as “In the thalmus, the most medial portions were relatively preserved (from the frontal cortex)“, and “The frontal temporal and temporal poles and insular-cortex demonstrated relative preservation” and “The granular neurons of the cerebral cortex were relatively preserved, while the larger pyramidal neurons were globally absent”, and “There was laminar necrosis involving the middle cortical lamina, in most cortical sections examined microscopically, but this finding was patchy”. (emphasis added)

Is it possible that some neurologist or radiologist might look at this and say, “My God, there was cortex left—an MRI should have been performed while she was alive”, or “That looks like the brain of one of my Alzheimer or Cerebral Palsy patients”?

I’m telling you, folks, that I can think of no reason for a defense of the decision (made by the judge and guardian) to deny Terri an MRI to exist in the neuropathologist’s report—except to provide cover. At the very least, inclusion suggests a predisposition to me—especially in light of the fact that he had to concede that you cannot diagnose PVS by autopsy.

Perhaps this wouldn’t bother me so much if he had been straight about the authoritative source upon which he bases his argument. He cites the source as if it definitely ruled out MRI in Terri’s case because of her implants—without telling the reader that the MRI is contraindicated in the case of some—not all neurological stimulator implants as I wrote last night.

Do not take the press reports at face value. Read the report yourself.

To be continued….

The media reports of Terri’s autopsy should not be accepted as all there is. Go read the report for yourself. Then go compare it to the opinions previously expressed by Dr. Boyle at Codeblueblog about the cortex as noted on the C.T. scan.

The autopsy shows necrosis and atrophy—but does not say that the cortex is gone! (page 8 & 9 of Nelson’s report on the brain) As Dr. Boyle says:

This is an atrophied brain, yes, but there is cortex remaining, and where there’s cortex (?life) there’s hope.

On page 8, Dr. Nelson says this about the necrosis: “Similar neuropathologic findings have been described in status marmoratus, a form of hypoxic-ischemic perinatal brain injury, involving the basal ganglia, like cerebral palsy. (emphasis added)

Compare that with what Dr. Boyle at Code Blue Blog said about the CT Scan:

HAVE SEEN MANY WALKING, TALKING, FAIRLY COHERENT PEOPLE WITH WORSE CEREBRAL/CORTICAL ATROPHY. THEREFORE, THIS IS IN NO WAY PRIMA FACIE EVIDENCE THAT TERRI SCHIAVO’S MENTAL ABILITIES OR/OR CAPABILITIES ARE COMPLETELY ERADICATED. I CANNOT BELIEVE SUCH TESTIMONY HAS BEEN GIVEN ON THE BASIS OF THIS SCAN.


Dr. Nelson asserts that Terri suffered from Ex vacuo hydrocephalus and he apparently copied verbatim from this source —though without attribution—on page 8 when he says:

Ex vacuo hydrocephalus is merely the replacement of lost cerebral tissue with cerebrospinal fluid. Because no imbalance in fluid production and absorption exists, this technically is not hydrocephalus.

Here is an article describing ex vacuo hydrocephalus:

Hydrocephalus ex-vacuo occurs when a stroke or injury damages the brain and brain matter actually shrinks. The brain may actually shrink in elderly patients or those with Alzheimer’’s Disease, and the CSF volume increases to fill the extra space. In this instance, the ventricles are enlarged, but the pressure may or may not be elevated.

Dr. Boyle says this in the comments section of his post about the possibility of hydrocephalus ex-vacuo (which I hope he will further explain now that this report is out)

One more thing…part of the perception of Schiavo’s atrophy is THE SIZE OF THE VENTRICLES! To the interpreter of a CT scan, hugely dilated ventricles in the setting of diffuse atrophy suggests hydrocephalus ex vacuo: enlarged ventricles due to the NEGATIVE pressure effect of atrophied cortex. And this observation WORSENS the severity of the cortical atrophy in the perception of the interpreter.

Despite the spin of the MSM and the claims of some bloggers, the report does not confirm PVS. In fact it points out that PVS is a clinical diagnosis not a pathological one.

Finally, I don’t understand Dr. Nelson’s defense of the decision not to do an MRI. It adds nothing to the findings, is hardly objective and seems to serve only as CYA foliage. He bases it on potential harm that could have happened to Terri because of the implanted stimulators—but says nothing about whether those stimulators couldn’t have been safely removed. Further, he has a little problem with how he argues that part of his report, calling his objectivity in to question.

Dr. Boyle of Code Blue Blog disagreed with that assessment and he is a radiologist—the kind of dotor who would actually administer the MRI. He says in the post linked above (again in comments):

In addition, it is hard to believe that anyone inserted electrodes, in 1992, that had paramagnetic properties that would preclude an MRI of the brain currently. I doubt that. Most of those devices are titanium or stainless steel, which are unaffected by MRI. Besides, with MRI, in that type of situation, the only reason not to do an MRI is because you are looking for information in the region of the artifact, where there would be distortion of the image.

If the items are not paramagnetic (like iron), there would be no danger and no contraindication to an MRI. Sounds bogus to me.

In his report, Dr. Stephens cites, FDA Public Health Notification: MRI-Caused Injuries in Patients with Implanted Neurological Stimulators, issued May 10, 2005. Dr. Stephens makes a blanket statement that the FDA warned in this publication that “serious injury or death can occur when patients with implanted neurological stimulators—such as the decedent’ s implanted thalamic stimulator—” undergo MRI. (emphasis added)

Here is what the above publication actually says :

This is to remind radiology personnel and physicians that serious injury or death can occur when patients with implanted neurological stimulators undergo MRI procedures, and to recommend preventive actions.

...snip…

If the patient does have an implanted neurological stimulator, consider consulting with the referring physician to discuss other imaging options. For some implanted neurological stimulators, certain MRI procedures are contraindicated and cannot be performed.

If an MRI procedure is to be performed on a patient with an implanted neurological stimulator, be sure to review the labeling for the specific model that is implanted in the patient, with particular attention to warnings and precautions. The radiologist may need to consult with the implanting or monitoring physician for this information. Also note and follow any instructions exactly for MRI imaging that may be in the labeling for the implant, including information on types and/or strengths of MRI equipment that may have been tested for interaction with the particular implanted device. The radiologist may need to consult with the device implant manufacturer for this information. (emphasis added)

He gives no evidence to support his implication that Terri’s implant was one for which an MRI was contraindicated. He just infers that hers is like the ones the FDA is warning about with no evidence.

Further, this warning makes it CLEAR that the implant does not necessarily rule out an MRI—it simply enumerates precautions to be taken.

I have a real problem with how this doctor characterized this FDA warning and how he gratuitously stuck in this information which is irrelevant to the purpose of the autopsy. Why doesn’t he cite information definitively stating that the exact type of implant in Terri’s head contra-indicates an MRI because the manufacturer so states?

I smell a credibility problem here.

To be continued…


Another point. To what extent did the prolonged dehydration contribute to the findings of brain atrophy and weight of the brain? Here is an abstract of a scholarly article on the effects of dehydration on brain volume:

The authors show that dehydration and rehydration can significantly change brain volume: lack of fluid intake for 16 hours decreased brain volume by 0.55% (SD, ±0.69), and after rehydration total cerebral volume increased by 0.72% (SD, ±0.21).

What will weeks of dehydration do?