Official News of Hillary Clinton’s Medical Condition Is Confusing
I concur with Richard Bazell, NBC’s head science reporter, that information dispensed from the State Department about Hillary Clinton’s medical condition is very confusing. The given and widely reported news is that Clinton suffered a “blood clot” “stemming from” her recent concussion, and that this blood clot is being treated with anticoagulants (eg, heparin or warfarin). However, the kind of blood clot most likely to occur in association with a concussion, a subdural hematoma (which is not really a “blood clot,” that is, a vascular thrombosis) would not be treated with anticoagulants—because anticoagulants would increase the risk of further bleeding.
The alternative explanation is that Clinton has suffered a deep venous thrombosis (DVT) in one of her legs—possibly as a result of prolonged sitting during extended and frequent plane rides and/or prolonged bed rest due to her recent (acknowledged) gastroenteritis. To reduce the risk of a pulmonary embolism as a result of the DVT, Clinton would, in this case, be treated with anticoagulants; however, this condition would not have occurred as a direct result of her concussion (which was reportedly due to fainting because of dehydration [which was due to the gastroenteritis]). Another alternative explanation is that Clinton was discovered to have a venous sinus thrombosis in the brain (possibly as a result of dehydration, and NOT a concussion) during her medical follow-up, and that this condition is being treated with anticoagulants. A third possibility is that the anticoagulants were prescribed to treat a stroke caused by an arterial thrombosis or embolism (in which case the anticoagulant might actually be tPA).
Until we receive a better a-to-b-to-c explanation about Clinton’s condition and why she’s receiving anticoagulants (and what kind), we’re left grasping at more logical and medically sensible explanations than the State Department is currently willing to offer.
tPA = tissue plasminogen activator.
Update: Follow-up news reports indicate that Clinton will remain hospitalized (at New York Presbyterian) for 48 hours. The timing suggests that Clinton is being anticoagulated with IV heparin before the effects of oral warfarin can kick in. The forecasted brevity of her hospitalization also suggests that Clinton is being treated for a DVT, as opposed to a more severe “blood clot” or thrombosis, such as a venous sinus thrombosis or an arterial thrombosis in the brain. If true, then her “blood clot,” as it was reported by the State Department, doesn’t have anything directly to do with her concussion.
01/01/13 update: Surprise. News reports indicating that Clinton would be hospitalized for 48 hours were premature or simply incorrect. The LA Times now reports that Clinton has a thrombosis in the right transverse venous sinus. The thrombosis was discovered on Sunday, December 30th, after Clinton underwent a brain MRI as a follow-up study for her concussion. No one is reporting whether Clinton experienced persistent symptoms after her concussion, such as a prolonged headache, which might have warranted the follow-up imaging study; however, there is apparently no indication that she suffered a stroke as a result of the thrombosis (which would most likely be, if it occurred, a hemorrhagic stroke). The prescribed anticoagulant therapy is intended to reduce the risk that the thrombosis will propagate further and to allow the body to dissolve (more or less) the obstructing clot. Some doctors uninvolved with Clinton’s care are offering that the concussion may have triggered the thrombosis; however, I find that explanation unlikely (but not impossible). While injury (eg, neurosurgical injury) has been epidemiologically linked to the formation of venous sinus thromboses, the relation of this condition to concussion is apparently confined to case reports (most of which are not in English). Given Clinton’s history, it seems more likely that she was predisposed to thrombosis on the basis of some as-yet undetected hypercoagulable state, with or without the aggravating variable of dehydration. Alternatively the condition is idiopathic (meaning the idiots don’t know what the pathology is). You can be sure, though, that her physicians are investigating with gusto the usual suspects for hypercoagulability (eg, protein C deficiency).
A native East Tennessean, Barbara Martin is a formerly practicing, board-certified neurologist who received her BS (psychology, summa cum laude) and MD from Duke University before completing her postgraduate training (internship, residency, fellowship) at the Hospital of the University of Pennsylvania in Philadelphia. She has worked in academia, private practice, medical publishing, drug market research, and continuing medical education (CME). For the last 3 years, she has worked in a freelance capacity as a medical writer, analyst, and consultant. Follow Dr. Barbara Martin on Google + and Twitter.
