What Causes Delirium After A Lumpectomy Surgery?

Posted on Mon, 13 Nov 2017

Question: MY MOTHER IS 78 YEARS OLD, SHE HAD A LUMPACTOMY ON 8/9 WHICH WAS NOT HEALING WELL AND HAD TO GET A WOUND VAC. THEN ON 9/2 SHE HAD TO HAVE HER DEFIBULATOR MOVED THE LEFT SIDE TO THE RIGHT SIDE FOR RADIATION TREATMENTS. ON 9/28 I TOOK HER TO THE ER BECAUSE SHE WAS HAVING A GOOD AMOUNT OF CONFUSION. SINCE THEN SHE IS NOW HAVING ALMOST TOTAL CONFUSION AND DELIRIUM. THEY HAVE PERFORMED ALL THE TEST THEY CAN THINK OF WITH NO ANSWERS. HELP

Answered by Dr. Ishu Bishnoi (2 hours later)

Brief Answer:
Possible causes and need some information

Detailed Answer:
Hi xxxxxx, thanks for asking from HCM.

I can understand your concern. Your mother is having few issues which are lumpectomy, radiation treatment and cardiac disease (using defibrillator). Confusion and delirium in such case can be due to

- Brain pathology like metastasis from breast malignancy or diffuse cerebral atrophy or radiation toxicity. I need her MRI brain films. May you please send me the films?

- Electrolyte imbalance - Deterioration of sodium/potassium/calcium level can cause such problem. It can happen due to vomiting, poor oral intake, loose stools following radiation.

- liver or kidney derangement - As she is having multiple issues and receiving radiation, her liver and kidney can get easily compromised. Need to rule out it.

- Psychosis due to radiation toxicity/brain atrophy. It can be suspected if everything comes normal and she is not improving. Psychiatrist opinion is needed to rule out it.

I need her blood reports and MRI brain films to suspect some organ. Please message me.
Hope you will understand my point. If any doubt, do let me know.
Thanks. Take care.

Above answer was peer-reviewed by : Dr. Yogesh D

Follow up: Dr. Ishu Bishnoi (16 hours later)

She has not had any radiation as of yet. They have not done an mri because of the defibulator. all blood test and spinal fluid have come back negative.They have ruled out strokes and cancer in the brain with ct scan with contrast.Her potassium level was low so they have been giving her potassium.They keep wanting to do an mri but that option is not available what can we do. Oncologist says it is neurological. Something is happening in her brain what can we do. Do not think neurologist is reaching out for help. He is the only neurologist at that hospital. I am trying to get her transferred to a bigger hospital for a second opinion. Also that is why I am reaching out to you.She also fell out of the bed on 9/7 and fractured her rib, said she has not felt well since. The lumpectomy was on 8/9. Then the moving of the defibulator was on 9/1.

Answered by Dr. Ishu Bishnoi (8 hours later)

Brief Answer:
Cerebral atrophy and electrolyte imbalance could be the cause

Detailed Answer:
Hi XXXX, welcome back.

I got your point. As MRI brain can not be done, proper evaluation of brain is not possible. But as per her age, multiple issues and intermittent cognitive impairment (slurred speech, confusion), it could be due to

- Age related cerebral atrophy - It is normal ageing process. The brain starts shrinking in size after 60 years age. It is progressive phenomenon. Your mother might be having symptoms of it. Currently she is manifesting intermittent symptoms that means it is the beginning only.

- Electrolyte (potassium imbalance) - Low potassium can impair nerve conduction and muscular contractions. As mentioned by you, she is getting replacement of it, she should improve with normalisation of potassium level. Low potassium can be due to poor oral intake, bed ridden stage, medication like diuretics, multiple diseases.
If she recovers completely, it could be the sole reason for her symptoms. If symptoms still persist, then diffuse cerebral atrophy can be other cause.

- Dementia due to Ischemic brain disease/Alzheimer disease can not be confirmed at this stage. What you can do is get her higher mental function examination done. It will confirm the degree of damage. We can suspect these pathologies if there is no improvement with medication and other measures. If possible get USG doppler of neck vessels or CT angiography of brain and neck vessels to rule out any arterial disease/narrowing.

Till confirmation, few medication can be given to her for recovery

- Citicoline
- Cerebrohydrosylate protein
- Donepezil
- Neuron specific vitamins like B12, folic acid, Pantothenic acid, pyridoxine.

You can start these medication after prescription. I usually manage my dementia patients with these. The response is slow but they usually show definite improvement.

Hope it will help. If you have any doubt, do let me know.
Thanks. Take care.

Above answer was peer-reviewed by : Dr. Raju A.T

Follow up: Dr. Ishu Bishnoi (18 minutes later)

Thank you very much, I will ask her doctors about this

Answered by Dr. Ishu Bishnoi (1 hour later)

Brief Answer:
Thanks

Detailed Answer:
Hi XXXX, thanks a lot for the appreciation.

Please let me know the updates. I will be happy to help you.
Take care. Best wishes for your mother's recovery.

Above answer was peer-reviewed by : Dr. Nagamani Ng

Follow up: Dr. Ishu Bishnoi (13 hours later)

I have asked the hospital if the tests you mentioned were performed and they said yes, with negative results. I keep asking the same question "If you can not do an MRI, what test can you do that is comparative? There has to be something.

Please help me, help my mother.

Answered by Dr. Ishu Bishnoi (18 hours later)

Brief Answer:
Perfusion scan and CT angiography

Detailed Answer:
Hi XXXX, welcome back.

As MRI can not be done, it is difficult to completely understand brain's anatomy. However ischemic damage to brain can be ruled out with

- CT perfusion of brain

- CT angiography of neck and brain vessels.

It will rule out ischemic cause of dementia. Please discuss above possibilities with treating doctor and let me know.
Hope it will help you. Thanks. Take care.

Above answer was peer-reviewed by : Dr. Kampana