Sunday, July 26, 2015

Blog #60: The Autopsy and Epilepsy

Blog # 60
July 26, 2015

          I recently led a neuropathology conference in the pathology department of a large county hospital where I teach neurology. First, the neurology resident described the patient’s medical history to the students and doctors present. The pathologist who performed the autopsy discussed the general overall findings. Then an academic discussion describing the disease process was held, including the results of treatment and what other diagnostic considerations could have been entertained.
          Next, we examined the brain. It had been soaking in a formalin bath for over two weeks to firm up the brain so it can be cut and examined. Fresh brains are like jello and the anatomy is easily distorted by simple finger pressure. I never cease to wonder how this two-pound organ contains all who we are. We examined the external surface for atrophy (e.g., Alzheimer’s disease), hardened areas (tumors), softened areas (strokes, infections), discolorations (hemorrhages), blood vessels (for hardened arteriosclerotic arteries, bulging aneurysms), brain malformations and for other problems. These can all be a cause for epilepsy.
          I used a special long razor-sharp knife and cut from front to back through the brain, starting at the top. I laid sixteen slices out on the table and we examined their appearance and pointed out the anatomy. Representative small pieces were then selected for pathological studies under the microscope.
          If the patient had epilepsy, too oftenup to one-half of patientsno definite cause can be detected by brain scan MRIs, CT scans, PET scans and various other studies, including under the microscope.
          Fifty years ago autopsies were performed in one of every two people who died in hospitals in the United States. My neurology training program, around 1970 at Case Western Reserve University Hospitals in Cleveland, had a weekly brain cutting conference. We averaged two brains to study each week. It was a highlight of my neurology education. But, the brain cutting session described above was the first brain that became available in our particular county hospital in almost two years.
          Previously, in order to be accredited, hospitals were required to perform autopsy-post mortem examinations on at least 20 percent of the deaths in hospital. That requirement was removed after 1970. Currently, autopsies are performed on only 5 percent of hospital deaths; many hospitals don’t perform them at all. The post-mortem examination often reveals that missed diagnoses and the wrong clinical diagnosis before death were made by the doctors who cared for the patient.1  Studies have found that significant errors occurred in up to 40 percent.2
          It’s no wonder these diagnostic discrepancies exist, even with sophisticated MRI scans. Over recent decades young doctors have rarely witnessed autopsies and they are reluctant to request it from the patient’s relatives. They are not aware that evidence of a post-mortem examination is invisible in the mortuary. The removal of the brain and internal organs will leave no observable marks. The autopsy can be done within hours; the body then is released to the mortician.

1.      Nashelsky MB1, Lawrence CH. Accuracy of cause of death determination without forensic autopsy examination. Accuracy. Am J Forensic Med Pathol. 2003 Dec; 24(4):313-9.
2.      Lundberg GD. Low-Tech Autopsies in the Era of High-Tech Medicine. JAMA, 1998; 280: 1273-1274.

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook, audiobook and soft cover editions.