Monday, December 18, 2006

Will Senator Tim Johnson condition improve to baseline? I hope so but odds are getting longer...

I think Hugh Hewitt's instincts were correct when he asked me on air to respond top the fact that none of Senator Johnson's M.D.'s had given a press conference. Johnson's surgery was Wednesday night and lasted 5 hours. As I have written before that is a very long time. Either the AVM malformation is in a very difficult to reach part of the brain:
1. bad news as this would mean they probably could not resect all of it or iatrogenic(medically induced trauma as the result Medical Treatment) brain damage was a big concern of the Neurosurgeon and maybe did occur.
2. or the AVM was so large and so complicated a tangle of blood vessels that the resection of this congenital web of malformed arterial and venous junction of vessels was a mess:
3. In this situation as your Denver Radiologist suggested, a second nonsurgical procedure known as an "emobolization" may be required.
      a. This is essentially a plug( bead, coil, glue, or balloons) is floated into the vascular system via an arteriogram which. This therapeutic "Plug" will flow down stream until it becomes jammed in the malformed AV junction. This in effect blocks up the vascular abnormality taking it on line.
      From With this procedure an angiogram becomes a therapeutic tool. The interventional angiographer is capable of filling the malformation with agents which help decrease the blood supply to the malformation (coils, glues, plastic spheres, balloons, etc). This makes surgery easier in some cases. The technique has been used as the primary treatment as well, and has apparently been successful in some cases.
      **This would be the choice treatment prior to bleeding/rupture having taken place as it would avoid iatrogenic complications
  • In Senator Johnson's case this procedure can be used as an adjunctive treatment after the surgery initially performed to remove the accumulated blood from the AVM rupture and excision of the AVM.
The press and treating Physicians continue to be nebulous about his condition.
Doctors have said Johnson will remain hospitalized until his brain swelling subsides and he will need physical therapy for weakness on the right side of his body. They also have not ruled out the possibility of further surgery
"Sen. Johnson remains in critical but stable condition, resting. At this point, no news is good news," a spokesman for the senator, Noah Pinegar, said via e-mail.
Physicians on the medical team treating him were heartened by how Johnson emerged from the surgery that took place late Wednesday.

"He is now stabilized and continues to show signs of responsiveness to the medical staff and the family," Dr. Anthony Caputy reported Friday. Caputy is chairman of the hospital's department of neurosurgery and was among three surgeons treating Johnson.
"No news is good news. Today is about rest," Johnson's spokesman Noah Pinegar said Saturday.
Pinegar said doctors were not predicting that Johnson would hit any specific benchmarks of recovery Saturday.

"A day-and-a-half ago, they talked in terms of a 72-hour time frame" that would give some solid indication about how well Johnson was recovering from the event. "We've got 36 more hours to go on that time frame," Pinegar said.
Pinegar said Saturday that doctors still cannot say whether those symptoms will abate following the surgery to relieve the pressure on Johnson's brain caused by the bleeding or whether Johnson will need speech or physical therapy.
"It's too early to know any of that," he said.
Sen. Tim Johnson continued his recovery Sunday, resting throughout the day at George Washington University Medical Center.

His condition, as anticipated, remained unchanged: critical, but stable.

"Nothing has changed," spokesman Noah Pinegar said. "It's been another day of rest for Tim, which is good at this point."
Johnson is recovering from bleeding in his brain that occurred Dec. 13 as a result of a congenital circulatory condition, and from the surgical procedure that drained the excess blood and stopped its flow.
Pinegar said he thought the timetable that would soon provide doctors with more insight into Johnson's recovery still was applicable. That Johnson has experienced no further bleeding and required no additional surgery is, of course, a positive sign.
  • Senator Johnson remains in the ICU in critical but stable condition. "Considering his initial presentation, his progress is encouraging. He is now stabilized and continues to show signs of responsiveness to the medical staff and the family" says Dr. Anthony Caputy.
  • Routinely patients with an intracranial hemorrhage experience post-operative swelling of the brain. "Much like a bruise, it takes time to heal," says Dr. Caputy.
  • Post-operative monitoring includes regular CT Scans. The most recent was done this morning.
  • Says Dr. Vivek Deshmukh "His most recent CT Scan shows that the pressure has been relieved from his brain and there is no further bleeding. Currently his brain pressures are normal and we will continue to monitor this closely for several days."
  • As a preventative measure doctors placed a filter in his vena cava last night. "Using state-of-the-art intravascular ultrasound at his bedside, we placed a removable MRI-compatible filter into his vena cava to reduce any risk of blood clots going to the lungs," says Dr. Anthony Venbrux.
  • It is anticipated that Senator Johnson will be in the hospital until brain swelling goes down and his overall condition improves. As he presented with weakness on his right side, doctors anticipate that physical therapy will be part of recovery.
Johnson `Conscious' at Times, Remains in Critical Condition: from Bloomberg  5 hours ago Monday 18, 2006
  • Senator Tim Johnson, a South Dakota Democrat, has been conscious occasionally and remains in ``critical but stable'' condition as he recovers from brain surgery, said his spokeswoman, Julianne Fisher.
  • ``He has been conscious at times,'' Fisher said. ``That's when he is opening up his eyes and responding to voice commands and touch. But he is being sedated so he can rest and heal.''
In my 25 years of experience of treating Brain Injury dealing, the the ~120+ hours since surgery and the clues about the severity of Senator Johnson's neurological deficits including lethargy, lead me to think that the Prognosis is poor for complete recovery.  One very good sign is the report that he has had the normal Intracranial Pressure which is a big positive as high Pressure can cause Brain damage. 
However, the weakness on the right side and lethargy are not good signs of a full recovery. Right sided weakness is indicative of a left side brain injury. Usually the left of the brain is responsible for language expression and reception(in ~ one-third of left handed people the speech center in located on the right side of the brain). Thus Senator Johnson may suffer from Aphasia or the inability to express himself. Additionally if severe Aphasia aka "Global Aphasia" he will not be able to understand language as well as not be able to speak. .
Additional deficits with left sided Brain damage beside the right-sided physical weakness include
  1. difficulty listening,
  2. understanding,
  3. gesturing,
  4. reading,
  5. arithmatic & math difficulty
  6. or writing aphasia(speaking & understanding)
  7. and impulsive.
  8. They'll typically perform tasks slowly and cautiously.
  9. impair swallowing
  10. cognitive functions
  11. left gaze preference,
  12. right visual field cut/loss

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