Chapter 146: Critical Diagnosis: A Turning Point

Epilepsy is often caused by excessively synchronous, abnormal brain discharges. An EEG can confirm the diagnosis by revealing spike waves, sharp waves, spike-slow waves, or spike-slow complexes.

It also provides valuable insights for physicians to determine the seizure type and the location of the abnormal discharges.

Zhou Can studied the patient’s EEG intently.

He even compared it with the pre-admission recording.

Soon, he noticed a marked difference in the peak amplitudes between the two.

The sharp wave components, surprisingly, had sped up considerably.

Moreover, the second EEG showed a significant increase in scattered abnormal waves.

“Xiao Zhou, what’s your diagnosis?”

Director Wen, it seemed, also wanted to test Zhou Can’s depth.

He was eager to see how the trainee performed beyond his placement technique.

All eyes were now fixed on Zhou Can’s face.

“I’m just a rookie—I’d better not risk embarrassing myself,” he muttered.

Having just joined Director Wen’s medical team, Zhou Can felt it wise to remain modest.

He recalled his parents’ timeless advice: fewer words mean fewer slips.

“Come on, speak freely!”

Director Wen insisted he share his thoughts.

Such an opportunity for evaluation was not one to be missed.

This challenging case was a true test of a doctor’s comprehensive diagnostic ability.

“Then I’ll humbly share my view,” Zhou Can admitted.

He decided not to hold back any longer.

“I compared the preoperative and postoperative EEGs. Both the pace of the sharp waves and the number of scattered abnormal waves have increased significantly after surgery.”

Director Wen nodded slightly at his observation.

For a trainee, spotting so many abnormalities in such a short time was impressive.

“Go on,”

he urged, signaling Zhou Can.

“From the EEG comparisons, it’s clear that the surgery not only failed to resolve the issue but actually worsened the condition.”

The office fell into a heavy silence as he spoke.

Many watched him in astonishment.

Was he unaware of what could or couldn’t be said?

Could one really insinuate that Director Wen’s surgery was flawed, even indirectly?

Director Wen’s formerly genial smile froze in place.

Although he hadn’t exploded, the simmering anger was palpable.

He refrained from pounding the table or berating Zhou Can, bound by his position.

“Go on!”

Director Wen’s tone turned notably cold, his words clipped and severe.

His icy gaze bore into Zhou Can.

Anyone who disrespects a superior doctor isn’t worth nurturing.

No amount of ability could redeem that mistake.

“Now, look at the preoperative and postoperative CT scans. Clearly, the surgery completely cleared the original lesion. Frankly, achieving such a thorough resection of abnormal veins near the internal capsule—without causing any damage—is beyond the capability of an ordinary chief physician.”

“At the very least, only an expert-level neurosurgeon could pull that off.”

Zhou Can’s tone rose gradually, starting meek before gaining strength.

His few words sparked a burst of applause.

Director Wen’s sullen expression quickly brightened; his smile returned, even warmer than before.

He felt as refreshed as if sipping a cool drink on a scorching June day.

Admittedly, the tactic of underplaying before praising was far more effective than blatant flattery.

Zhou Can hadn’t intended to butter up Director Wen.

He was merely speaking the truth.

Perhaps even he was surprised by the unanticipated positive effect.

Emotional intelligence, he mused, was crucial from a young age.

Once deeply ingrained, it prevented missteps in both speech and actions.

Since joining the trainee program at Tuyu Hospital, Zhou Can had defused multiple crises with his high emotional intelligence.

Both Deputy Director Bai and Shangguan Yan from Tuyu Affiliated Hospital No.2 had switched from opponents to allies, grateful for his assistance.

Had it been anyone else, the outcome might have been entirely different.

“Haha, this surgery was indeed challenging, but claiming that only expert-level neurosurgeons can perform it is a slight exaggeration!” Director Wen admitted, his laughter breaking through despite his guarded nature.

Even the most calculating schemer couldn’t resist the genuine mirth that Zhou Can’s modest yet pointed remarks invoked.

He was, after all, truly delighted.

His heart felt as if it were brimming with honey.

After the surgery’s complications, Director Wen had borne immense pressure and feared criticism for a flawed operation.

Now, Zhou Can’s public vindication—highlighting both the strengths and critical challenges of the surgery—was a relief.

How could he not be pleased?

It was not only a nod to his surgical prowess but also high praise for his specialization.

It was far more authentic than the empty compliments some offered.

“I’m not exaggerating. Resection of abnormal veins near the internal capsule is a challenge second only to operating near the brainstem. Many chief neurosurgeons wouldn’t dare attempt it; those who do are exceedingly rare.”

Zhou Can continued to commend Director Wen.

Throughout, he never once mentioned Director Wen’s name.

Yet, Director Wen found his words immensely gratifying.

Flattery, he mused, was truly an art—it wasn’t about generic praise like ‘you’re talented’ or ‘you’re handsome’…

The finest flattery struck directly at the heart, earning genuine recognition.

Only then could one secure deep approval.

“Based on the abnormal points on the postoperative EEG and the CT scan, I believe the patient’s worsened epilepsy is due to one of two possibilities: a brain hematoma or another undetected lesion.”

Vascular malformations are rarely isolated; they usually occur in multiples.

Experienced doctors often recommend examining the arteries and veins from the neck upward.

“Well said!”

Director Wen expressed his heartfelt admiration for Zhou Can’s insight.

Had Dr. Zou or Tang Li offered the same diagnosis, he might not have been as impressed.

After all, they were both seasoned attending physicians.

Though their interventional skills left much to be desired, their academic and diagnostic capabilities were solid.

Within the realm of neurosurgery, they ranked among the best.

For a trainee to display such acumen was nothing short of remarkable.

“Dr. Zhou, I never imagined you could excel not only at placements but also in diagnostics far beyond our own. The three of us have much to learn from you.”

The three graduate students smiled warmly at Zhou Can.

It was a gesture of goodwill.

“Recognizing two distinct causes is impressive, but to truly treat the patient’s epilepsy, we must pinpoint the primary lesion. Can you refine your diagnosis even further, Dr. Zhou?”

Dr. Zou remarked with a smile that barely concealed a hint of sarcasm.

For a trainee, approximating the diagnosis was already an achievement.

Asking Zhou Can for more precision felt almost like setting him up to lose face.

As an attending, having his expertise overshadowed by a trainee in the OR—and now in discussions—was hard to swallow.

Dr. Zou couldn’t help but harbor some unkind thoughts.

Suppressing newcomers had long been the favorite tactic of veteran doctors.

“I’m uneducated and inexperienced; I dare not speculate recklessly in front of seniors like you.”

Quick on his feet, Zhou Can deflected the pressure with a couple of light remarks.

Then he shifted the topic.

“Dr. Zou, since you’re asking, you must already have an answer. Why not share it so we rookies can learn?”

In doing so, he effectively turned the tables on Dr. Zou.

With a status far higher than his, Dr. Zou found it hard to sidestep the question.

“Uh… well, I believe there’s a greater chance of vascular malformations elsewhere.”

Dr. Zou stuttered, clearly unprepared.

He didn’t have a precise diagnosis in mind.

He could only offer a vague reply.

“Dr. Zou, I heard that a preliminary location of the lesion can be deduced from the EEG. Could you specify which vascular region is affected and whether the abnormality is severe?”

A graduate student inquired.

This fellow clearly wasn’t trying to gang up on Zhou Can.

It was simply a strong desire to learn.

“Um… I personally suspect it’s near the cerebral peduncle. As for the severity, we’ll have to await the test results,” he offered.

Dr. Zou’s response exuded a deep lack of confidence.

It remained vague and inconclusive.

If this were the basis for surgery, it would be useless.

An unclear lesion location and ambiguous condition were nothing but guesses. Could that satisfy surgical criteria?

“Lesions in the cerebral peduncle can essentially be ruled out. In my experience, vascular malformations causing epilepsy have never been seen in that area. The cerebral peduncle functions more as an endocrine center; any pathology there would typically trigger systemic hormonal imbalances or drastic changes.”

Director Wen immediately shot down Dr. Zou’s diagnosis, leaving no room for debate.

There was no margin for error.

Medicine must be precise and meticulous—there is no place for ambiguity.

“Everyone, please review the patient’s preoperative cerebral angiography. See if you can locate the lesion. And, as Dr. Zhou mentioned, a postoperative hematoma is also a possibility; reexamine the CT scan to deduce the cause.”

Director Wen gave the team a general direction.

However, the exact lesion location and its cause were still unclear.

Discussion flowed as everyone offered their insights.

Each person voiced their opinion.

While poring over the scans, Zhou Can also recalled the patient’s specific symptoms and various manifestations.

In the end, he reached a startling conclusion.

“Director Wen, is it possible that the patient has a cavernous hemangioma?”

Zhou Can looked up and asked.

“It can’t be ruled out!”

Director Wen, though not a miracle worker, certainly had more diagnostic experience and deeper knowledge of cerebrovascular and neurological conditions than any of them.

“Cavernous hemangioma is a covert vascular disease. Even with CT or the most advanced digital subtraction angiography, it is very hard to detect. I think it’s necessary to request an MRI for the patient.”

Zhou Can was convinced that a cavernous hemangioma was highly likely.

On the other hand, an intracranial arteriovenous malformation could essentially be ruled out.

If an arteriovenous malformation were present, even a tiny one, it would have been detected long ago.

Tang Li voiced her concern, “The hospital’s MRI resources are extremely limited and expensive. Will the family accept it? The family of the patient in Bed 22 was notoriously hard to persuade during rounds. Now, with the patient’s condition worsening post-surgery, explaining it as a complication feels a bit far-fetched—and the family’s trust in us is already very low.”

Her worries were not without reason.

The doctor-patient relationship was already highly strained.

Especially once trust had been breached, the situation would only deteriorate.

And since the patient had already undergone two postoperative examinations, demanding another expensive MRI might trigger an uproar.

“We doctors aren’t miracle workers either. We did remove the abnormal venous lesion, yet the worsening epilepsy can only be attributed to either a postoperative hematoma or other vascular anomalies. All previous examinations and exhaustive preoperative discussions have ruled out ordinary vascular issues. Only the so-called covert vascular disease—a cavernous hemangioma—seems likely.”

“For further treatment, there’s no bypassing this issue. Frankly, a postoperative hematoma would have been obvious on the CT scan. Since none was found, I believe an MRI is indispensable.”

Compared to CT, MRI provides far more definitive and precise results.

It was the advent of MRI that once allowed many tumors to be easily diagnosed.

It has unique advantages that neither ultrasound, X-ray, nor CT can match.

Director Wen lowered his head in deep contemplation.

As a chief physician, he naturally had his own insights.

Zhou Can’s suggestion was only meant as a reference.

The team continued their discussion, each doctor contributing their thoughts.

Gradually, more doctors supported the MRI approach.

They systematically eliminated various possibilities.

They ruled out potential causes one by one.

Ultimately, the likelihood of a cavernous hemangioma was seen as extremely high.

Cavernous hemangiomas have the characteristic of extremely thin vessel walls, increasing the risk of rupture and bleeding during surgery.

A head ultrasound can also offer diagnostic clues.

However, the family’s uproar was already intense.

Every examination order was issued with the utmost care.

Otherwise, the family might accuse us of profiteering—saying not only did the surgery fail, but now the patient had to undergo every test all over again.

“After careful consideration, I’ve decided to request an MRI for the patient’s head. Tang Li, you’re excellent with communication; could you discuss this with the family?”

In a medical team, everyone brings their strengths.

Maintaining good communication with the family is crucial.

“Alright, I’ll talk to them right away,” she replied confidently.

Tang Li agreed readily, exuding confidence.

Female medical staff naturally have an advantage in communicating with families.

They are more easily trusted and come off as empathetic.

Her demeanor was gentle.

“Just be honest. Explain the discussion in detail so they understand that the worsening epilepsy likely stems from dual lesions.”

Director Wen provided his guidance.

Many complex conditions can present with two lesions.

It’s like finding one rat in your home—it might indicate an infestation in the whole neighborhood.

……

Half an hour later, Tang Li returned after speaking with the family.

Her expression was relaxed, even sporting a faint smile.

It was clear the conversation had gone well.

“The family has agreed to the MRI. After our discussion, their trust in us has increased significantly. Now we can only hope the lesion is truly identified!”

Her biggest worry was that even the MRI might yield inconclusive results.

If that happened, any renewed trust would vanish completely.

The family’s trust in the hospital would be irreparably damaged.

After a long wait, good news finally arrived.

The head MRI revealed a sizable area of vascular abnormality inside the skull.

The radiology team, skilled at reading scans, quickly pinpointed the issue.

They clearly outlined the size and nature of the lesion.

Director Wen eagerly took the MRI films and examined them closely in the light.

A delighted smile gradually spread across his face.

“Excellent, simply excellent! It is indeed a cavernous hemangioma. This wretched condition nearly cost me my lifelong reputation!”

His self-deprecating exclamation drew chuckles from the other doctors.

“Xiao Zhou, your performance was outstanding. Honestly, if it weren’t for your rigorous analysis and insistence on ordering an MRI, I wouldn’t have known what to do. Our team officially invites you to join us; I’ll arrange an internal account for you so you can review cases anytime. Please keep me informed of any diagnostic breakthroughs.”

For a man as proud as Director Wen, giving public recognition to Zhou Can was no trivial matter.