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This just in via the NY Times regarding Hillary Clinton:

As a neurologist and epileptologist, this news worries me for several reasons.  First and foremost, a concussion is basically a bruise on the brain.  Often times, after a traumatic head injury such as the one suffered recently by Secretary of State Clinton after she as reported to faint and hit her head on the floor, concussions are also associated with small other intracranial problems like a subdural hematoma, which is the specific type of clot that I am willing to venture and guess she has (without knowing more information).

Normally, if one goes to the ER right after a head injury - protocol medicine usually warrants at least a CT scan of the head.  Subdural hematomas are usually incidental findings on such exams and when small enough, they are managed conservatively - no need for any neurosurgery.

I suspect that when Secretary Clinton didn't visit the hospital, as reported, her doctors would never have known if she also suffered from a subdural hematoma or other type of "clot".  I think it is only now, after Secretary of State Clinton has had a chronic headache that has been persistent for > 1 week that her medical team became concerned enough to do head imaging - such as a CT scan of the head (again, I don't know anything regarding her private medical matters - I can only speak from my experience as a neurologist) and this "clot" was only picked up now.

As such, even if this seems to be a minor injury - I worry about Secretary Clinton's future.  I hope she doesn't develop chronic headaches nor any long term sequela regarding this head injury, such as posttraumatic epilepsy.  I can only see the nefarious GOP partisans who will probably gloat that they can now attack Hilary's as her medical dilemma soon becomes more public.

Lets hope and pray that Secretary of State Clinton is okay and wish her well for a speedy recovery.  Sorry for the lack of details.

6:52 PM PT: I wrote the diary prior to learning that Secretary Clinton is now on anticoagulation.

Anticoagulation for subdural hematoma treatment is rather unusual.  If the clot is intracranial, then perhaps the anticoagulation is related to something like a dural venous sinus thrombosis or a cerebral venous thrombosis - two entities where anticoagulation is the standard of care.

Another possibility is that due to her sedentary nature over the past few weeks following her illness and concussion - she developed a clot elsewhere in her body - i.e. in her leg (known as a deep vein thrombosis - DVT) which also requires treatment with anticoagulant agents.

Thank "The George" for inspiring me to update.

Mon Dec 31, 2012 at 3:03 PM PT: As suspected in my previous comment, she has a dural venous sinus thrombosis - specifically a right transverse sinus thrombosis.

This can be dangerous if left untreated without anticoagulation.  These problems can be complications of traumatic head injuries (i.e. concussions) as well as be related to blood clotting problems/hypercoaguable states. The risk of dural venous sinus thrombosis can also occur during pregnancy and so a golden rule is that pregnant women who have persisting headaches without a history of headaches warrant immediate workup.

If the clot grows large enough, the flow of blood through the sinus in question becomes impaired creating a backlog of blood - that tends to pool without adequate outflow.  This leads to poor perfusion around the areas that are normally drained by the sinus in question and puts people at risk for ischemic strokes - a so called venous infarction.

Headaches are quite common with venous sinus thromboses.  Elevated intracranial pressure that may show up as papilledema on a fundoscopic exam as well as certain cranial nerve abnormalities may hint at the diagnosis (I once diagnosed a transverse venous sinus thrombosis in a pregnant female with left sided facial weakness - facial nerve palsy and a headache).

Even in the setting of a hemorrhage - anticoagulation is absolutely necessary which is quite counterintuitive from a medical standpoint.

Seizures can often be a presenting sign heralding workup that may reveal a dural venous sinus thrombosis.

Based on the standard of care - HRC will need to be on anticoagulation (most commonly - coumadin/warfarin) with therapeutic blood levels (INR needs to be between 2-3) for at least 3-6 months.

After a few months, her physicians will likely repeat an MRV of the head (MRI that specifically is protocoled to look at the veins of the head via the use of a contrast dye that "lights up" the blood vessels on a scan) to see if the clot still remains.  If there is no further clot evident on imaging, she is free to discontinue coumadin.  If a clot remains - she needs to be on coumadin for longer.

There are newer anticoagulants on the market that do not require as frequent monitoring of blood levels and may be more convenient for HRC to use - such as Pradaxa - however these newer anticoagulants haven't been used for long compared to something like coumadin.

The reason why HRC needs to be in the hospital is because as she starts coumadin - it doesn't have an immediate effect.  It has a long half life and takes several days to build up in the blood stream.  She concurrently will need to be on heparin until her coumadin levels are therapeutic.

I wish her well and a safe recovery. She is an amazing woman!

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