Hey Gabblers, ABC has posted a great explanation of the medicine behind the case Meredith and Bailey dealt with in episode 8.14. Read below if you’re curious.
By Meg Marinis, Director of Medical Research
- One young female.
- A psychiatric diagnosis (psychosis, acute schizophrenia, catatonia).
- Personality change.
- Unexplained headaches.
- Negative head CT.
- Negative basic labs.
- Normal physical examination.
Mix it all together, and what do you have? Yep. You got it: A good ol’fashioned medical mystery!
Janell’s medical mystery began with severe “blinding” headaches.
These headaches were soon followed by seizures. Most people associate seizures with the generalized convulsions — when the patient physically collapses and loses consciousness. However, Meredith could see that Janell actually experienced absence seizures – when the patient only loses consciousness for a few seconds and seems to stare blankly into space. The electroencephalogram (EEG) confirmed Meredith’s theory in that Janell’s seizures were continuing to occur, putting her at risk for permanent brain damage.
Meredith was suspicious that these seizures and changes could be caused by an infection in the brain. She did a lumbar puncture (commonly caused a spinal tap) and found that her cerebrospinal fluid contained increased white cells, but no bacteria. This ruled out meningitis, but, Meredith and Derek knew that Janell had some sort of encephalitis – irritation and inflammation in the brain. Symptoms of encephalitis include flu-like symptoms, fever, severe headaches, confused thinking, seizures, altered consciousness, and hallucinations (sound familiar?). They could start meds to make the inflammation go down, but without knowing the cause, they could not treat Janell’s encephalitis (or stop her seizures). Meredith and Derek placed Janell into a medically-induced coma to help stop the ongoing seizures while they came up with a diagnosis. With this type of coma, drugs will reduce the cerebral blood flow and the amount of intracranial pressure. With the decrease in swelling, doctors hope that permanent brain damage may be prevented.
Meredith noticed that Janell had a hemolytic anemia. This type of anemia signifies a decrease of red blood cells in the body due to an autoimmune response. Antibodies present in Janell’s body have launched an attack against these red blood cells, causing them to burst. Meredith had to ask: why is Janell’s immune system suddenly on the offensive?
Meredith thought that if there was something attacking the red blood cells, perhaps there was something also attacking the brain. She decided to check for something called a “paraneoplastic syndrome.” This is a syndrome where neurologic symptoms can be caused by some sort of cancer. She sent Janell’s blood and CSF off for special studies, and Janell tested positive for anti-NMDA receptor antibodies. Janell was making antibodies that were attacking normal brain tissue!
Meredith knew that these anti-NMDA receptors indicated a teratoma.
A teratoma is a type of germ cell tumor that may contain several different types of tissue — such as hair, muscle, and bone. The word “teratoma” is actually derived from the Greek word for “monster” because of their strange contents. They occur most often in the ovaries of women, the testicles in men, and the tailbone in children. Teratomas can be fairly small, often found accidentally during scans or surgery for other reasons. In Janell’s case, Meredith and Bailey saw a tumor in Janell’s lung. When tumors are found in that location, the diagnosis is usually one of six things (called the “6 T’s”): thyroid lesions, thymic and parathyroid masses, “terrible” lymphoma, tortuous vessels (like a dissecting aorta), trauma, or, you guess it, the infamous teratoma.
Since Meredith had scanned Janell’s entire body and they only saw this one tumor, which could very well be a teratoma, they decided to take that tumor out and hopefully solve the problem. Because of the location of the tumor, they couldn’t just do a biopsy — it was a major operation. Unfortunately the tumor was just a benign, insignificant mass, not the cause of this problem. So she went back to the drawing board. Different tumors have different tumor “predictors.” Turns out, anti-NMDA receptor antibodies are most often found in the ovary. Even though Meredith didn’t see anything there, she was pretty sure that there must be a microscopic tumor there, and since Janell was in such dire straits, she decided she would take the chance of sterility to try and save her life. Lucky for Meredith, she ended up being right.
Ever wonder what the heck a bilateral decompressive craniectomy is? I’m sure for most of us, we hadn’t heard of such a procedure before Meredith and Derek performed it last week on the injured professor. Meg Marinis, the Director of Medical Research at Grey’s explains the medicine:
Bilateral Decompressive Craniectomy
Written By Meg Marinis, Director of Medical Research
Happy New Year, and Welcome Back, Fans!!! I hope all of y’all had a wonderful and relaxing holiday!
… Especially since we brought you back with one highly intense episode, huh?
In Episode 711, “Disarm,” our doctors at Seattle Grace must confront their past trauma and treat victims from a local school shooting at Pacific College. The patients’ injuries range from life-threatening gunshot wounds to horrible psychological shock, reminding our characters of their terrifying experience six months ago. However, this tragedy ends on a much more uplifting and healing note for our doctors. Ambulances deliver twenty-six victims to the hospital. And each patient survives.
So, what exactly happened to Professor Sturgeon?
John Sturgeon, Derek and Meredith’s patient, fell four stories out the window while trying to help students escape from the building. And landed on his HEAD. When Sturgeon arrives at the hospital miraculously alive, he presents with an open skull fracture, blown pupil, and a sky-high intracranial pressure. Derek and Meredith rush Sturgeon to the OR because his brain is “herniating”—his brain tissue is being moved or pressed away from its usual position in the head.
The skull is usually very protective—helping us to save our brains when we hit our noggins. But in the case of increased pressure or a mass inside the brain, the brain needs to expand or swell, but there’s no extra room to do it. The brain has to find somewhere to go, so sometimes, if the pressure becomes too much, it will “herniate”—which means it will find new places to go to try and cope with the pressure. There are a few holes it can find and try to squeeze through, but simply the squeezing itself can inflict damage to the delicate brain cells and brain tissue. And when the damage is coupled with potentially squeezing into a space that compresses the brain stem, POOF! There go your vital functions.
Derek and Meredith performed a cranie—what?
In order to let Sturgeon’s brain swell (and thereby heal), Derek and Meredith perform a decompressive craniectomy—a procedure in which one part of the skull is removed to allow the brain space to swell and the pressure to decrease. But even after Derek and Meredith remove the left side of Sturgeon’s skull, the brain continues to swell. So they remove the OTHER side of Sturgeon’s skull, leaving a small strip of bone in the middle to protect the superior sagittal sinus (to prevent further complications with draining into the sinuses).
Along with removing the bone flaps, Derek also suctions out the damaged brain tissue. And rather than just leaving the brain out in the open, they sew the scalp and muscle over the exposed area. The patient then remains in a medically-induced coma in the ICU while the brain heals. Meanwhile, Derek and Meredith will place the removed pieces of skull into a medical freezer to prevent them from dying. And hopefully within a couple of weeks, Sturgeon’s brain swelling will decrease enough that they can bring him back into the OR to perform a cranioplasty and surgically put his skull back together.
What kinds of patients need a decompressive craniectomy?
Neurosurgeons perform the surgery on patients who enter the hospital with a severe form of traumatic brain injury (TBI), typically from motor vehicle accidents or high falls. These patients usually present on the Glasgow Coma Scale (a scale used to assess the level of consciousness after head injury) with a score of eight or less out of fifteen and sometimes also display fixed and dilated pupils and an unresponsiveness to light. After a set of CT scans to see the level of contusions, these patients are immediately rushed to the operating room.
Is removing part of the skull okay?
Even though studies have shown that this type of surgery can significantly and rapidly reduce intracranial pressure and improve survival, decompressive craniectomy has actually always been considered controversial and only advised as a last resort. Without a cranial flap, patients are theoretically at increased risk for additional injury to an unprotected brain. Complications associated with the procedure include delayed intracranial hematomas, development of hydrocephalus, fistulas, infection, and traumatic epilepsy.
So folks the Podcast for last night’s episode is up!! Click below to have a listen!
Thanks to Liat for letting us know about it and to SpoilerTV for posting it up!
Till next time,
Aussie Lee xxoo