MRI, and about those eyes....

Graham update Day 51 (July 29, 2014)

One thing we learned pretty early on following Graham's accident wherein a car ran over his head is that schedules are very fluid and ever changing in the hospital.  So it came as no surprise today that Graham's MRI, first scheduled for 8:00 AM, got pushed back to noon and didn't get started until well after 1:00  Graham has not seen anything out of his right eye since the accident, and his left pupil is fixed, so we were naturally VERY anxious to  get the results back.

Getting an MRI is not without its hurdles though.  During an MRI as detailed as Graham's, where they are looking at the brain in whole, and looking closely at the pituitary gland and the orbitals, one would have to lie motionless for 30-40 minutes.  This is normally a tough thing for adults to do, let alone a 6 year-old who, since his injury, gets distracted VERY easily.  The natural thing to do is sedate the child, but doing that requires fasting - not an easy thing for someone with diabetes insipidus to do.  That level of sedation required also requires a ventilator.

They actually wanted to do the MRI last Friday, but due to some issues with Graham's sodium (D.I. related) they pushed it back to today.  With lots of careful planning and D.I. management, the MRI did happen though, with Graham falling asleep with a smile on his face at 1:30 PM, and rolling back into his room, groggy but alert, at 4:00.

The results:  we don't have them yet.  For starters, the imaging took place late in the day, and when it takes a pair of neuro-radiologists to interpret them, that time window just won't do.  The other hang-up - they want to compare the results of the MRI to the results of a CT scan ( now scheduled tomorrow morning at 8:00), before they make any declarations about his injuries, but the good news is that as long as the CT scan happens, we should know a lot more about Graham's injuries tomorrow.

Therapy continues to go very well for Graham.  The name of the game is getting him to the point where it is safe for him to come home, and to that end they are working on getting up from a sitting position and then sitting back down again safely.  He can walk under his own balance and power still, although he is pretty wobbly so they don't think it is safe for him to do so just yet.

Graham will meet regularly with a Neuro Psychologist here at Cook Children's.  She met with him for the first time yesterday and just played with him. She brought a little sandbox and some fake dinosaur bones.  They played for a little while, and then Graham said "is it ok if my dad plays with us?"  Definitely music to my ears!  First I had Graham close his eyes and I buried the pieces, and then he opened his eye and dug for the bones.  We did this a couple times until it was my turn to be the paleontologist.  I closed my eyes, and while they were closed I touched a the foot of a white stuffed horse that was in Graham's bed.  Graham apparently saw this, and doing so completely threw Graham off - he picked up the horse, looked at it, and  eventually started talking about something else - completely forgetting that I had my eyes closed and was waiting for him to bury the bones.

After the session, I asked the Neuro Psychologist what her impressions were.  She said Graham was very complacent, which is not a bad thing.  He's just open to suggestion and is basically willing to do whatever.  She also said he wasn't the least bit agitated, which means he is coping well.  Then she said "he is really distracted.  I mean REALLY distracted.  We are in a pretty calm and controlled environment, and you saw how hard it was for him to stay focused.  Imagine if he was out with lots of people in a completely uncontrolled environment.  That wouldn't be safe for him yet." 

* * * * *

This picture here below is a 3D-rendering of Graham's CT scan taken the night of his accident.  You can see that his forehead was completely broken off across the orbital bones and the bridge of his nose, and that his entire forehead was shifted towards the left side of his face.  In doing that, you can also see that his upper-right orbital bone was actually pressing on the upper right portion of his right eye.  Shortly after the accident occurred, an ophthalmologist at Children's examined Graham and determined that the pressure in his eyes was OK, and that there was nothing that could be done immediately to help Graham's vision.  That was the last time that anyone took a close look at Graham's eyes - until today.

We were very fortunate to get a late visit from an ophthalmologist this evening.  He spent a good 15 minutes with Graham, doing a variety of tests, and this is what he found:

• Graham's left eye was his "bad eye" before the accident.  Graham has amblyopia, a type of lazy eye.  It means he didn't really use his left eye at all, although he had no issues with it wandering off like some with a "lazy eye" do.  When Graham's doctor examined his left eye today, he found that Graham had 20/100 vision in it - better than before his injury, and a HUGE blessing.  That pupil is still not dilating, and we were relieved to hear the doctor's explanation - he said it was most likely due to a mid-brain injury.  He sees it a lot, and expects that with time Graham's left eye will function normally.  This is GREAT news!
• Graham's right eye is another story.  He doesn't open it much at all, and tonight we confirmed he cannot see anything out of it.  The inability of Graham to move his right eye or open it is caused by damage to the third cranial nerve.  This is something that is inoperable, but that could potentially heal with time.
• The second cranial nerve could be the source of the actual blindness in Graham's right eye, and is what we hope to better understand with tomorrow's MRI results.  Depending on the severity of any potential damage to that nerve, it is something that could heal over time, or it could be permanent.
• There is, however, another issue that could be causing the blindness in Graham's right eye - Terson Syndrome.  In instances where people have high Intracranial Pressure (ICP), like when your head gets run over by an SUV, people can hemorrhage inside their eyeball, and the resulting blood can actually obscure all the light from hitting the back of the eye and flowing into the optic nerve.  Graham's doctor could VERY CLEARLY see Terson Syndrome in Graham.

So what does this all mean?  Graham's left eye will be fine, and get will likely get back to normal with time.  Graham's right eye is another story.  IF his optic nerve is undamaged, then his blindness is almost surely due Terson Syndrome, something that can be corrected surgically - you cut the eye open and scrape out the old blood.  This is our best-case scenario at this point.  Next best would be that a combination of optic nerve damage and Terson's are causing it, and the former will heal with time, while the latter will be repaired surgically.  If Graham's optic nerve is completely and permanently destroyed, though, the Terson Syndrome would be a moot point, and Graham and Dad would just need to go golfing a lot a together to help him adjust to having a new "dominant" eye.

So we are very hopeful that the MRI results are promising tomorrow both in terms of his vision and the overall health of his brain.  Any way you slice it though, it is a miracle that Graham is alive.  It is a miracle that he can walk, and talk, and see - even if it is out of one eye.  We are so grateful to the medical team - from the first responders to the staff at Children's to the amazing people here at Cook - for helping Graham get to where he is at today.  And we are grateful to our Heavenly Father for answering our prayers and the prayers of so many others on behalf of our sweet little Graham Hopper.  Thank you all for your prayers, and God Bless.