Case Brief:
Essentially: A 72 year-old suffered a left posterior middle cerebral artery cerebrovascular accident “likely secondary to emboli after the procedure.” He underwent surgery for a left carotid endarterectomy (for an 80% severe left internal carotid artery stenosis). There was EEG monitoring during the procedure. Specifically, the operative report notes…
SURGERY: 04/13/18
The internal, external and common carotid arteries were dissected out and vessel looped. The hypoglossal and vagus nerve were identified and preserved. Patient was heparinized to 2.5 times baseline ACT and acts were checked throughout the case. l then clamped the internal carotid then the common carotid and the external carotid artery. There were no EEG changes, however there were cortical SSEP changes on the right side. I immediately shunted with 10 French Argyle shunt by placing it in the internal carotid artery…
5:45 pm Surgery started
7:34 pm Surgery ended
8:04 pm Transferred to PACU
8:11 pm Consult ordered with pulmonologist
8:15 pm Surgeon at bedside, aware pt movement is unequal, only moves left side of body spontaneously and right food to painful stimuli
8:25 pm Surgeon at bedside, aware pt. STILL NOT moving right arm and appears to have a left lateral gaze,
8:30 pm Unequal extremity movement
LE Strength, Poor
UE strength -4
Right UE – 0 – no contraction
Systolic BP 152
8:40 pm Unequal extremity movement
LE Strength, Poor
UE strength -4
Right UE – 0 – no contraction
Systolic BP 140
Plan for CT, then ICU
9:30 pm right side mouth drooping (RN note)
9:44 pm Head CT prelim report given via telephone to surgeon:
PROBABLE LEFT WATERSHED INFARCTS. CONTRAST-ENHANCED BRAIN MRI ADVISED.
10:00 PM Surgeon at bedside (CT completed) Stoke alert called for evaluation and stat neuro consult Surgeon on phone with on call neurologist
On call stroke neurologist eventually consulted
2 days later:
04/15/18: Head MRI Results:
IMPRESSION Large posterior left MCA territory infarct with
additional areas of involvement scattered throughout the left
temporal and frontal lobes and left deep gray nuclei. Findings
suggest acute embolic event Possible small volume hemorrhagic
transformation the left parietal lobe. Follow-up head CT examination
advised.
Questions: 1. was this complication avoidable? 2. Once diagnosed, would have been any additional test or intervention indicated?
Files:
No questions yet!
Do you believe there might have been medical error?
Thrombosis of the endarterectomy needs to be ruled out as fast as possible. It appears the management included a CT brain, but not a CT angiogram of the arteries to rule out carotid thrombosis. Time is critical. Bed side ultrasound to prove that endarterectomy was not thrombosed would also be a rapid method to determine if thrombosis occurred. If there was thrombosis, return to the OR for thrombectomy would be next step. It is not clear from the records if this would have change the outcome, however. More information is needed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If there was thrombosis of the endarterectomized surface, neurological recovery may be more likely if the diagnosis is made quickly, and re-operation to remove thrombus. .However, there is no guarantee there will be any neurological recovery, but it may improve odds if diagnoses and remedied expediently. It is not clear that this was ruled out. However, more information is needed.
What makes you a good expert for this case?
Assistant Clinical Professor of Vascular Surgery Board Certified in Vascular Surgery
How often do you encounter cases similar to this one in your practice?
I have had a similar situation occur in my practice, I did identify thrombus using CT angiogram, and I took the patient back to the OR for thrombectomy.
Do you believe there might have been medical error?
Stroke can occur after any CEA - risk is about 1.5% in asymptomatic patients and may or may not be reduced when pt has an intraoperative shunt What is unclear in this case is why 2 hours elapsed from abnormal neuro exam to stroke alert - I would normally alert stroke team at the same time as obtaining non-contrast head CT, then go straight to catheter angiography for neurorescue.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Stroke can happen with any CEA. Time elapsed from abnormal neuro exam to stroke team activation requires more investigation.
What makes you a good expert for this case?
I do a lot of CEAs and carotid stents and have published about carotid disease in peer reviewed journals.
How often do you encounter cases similar to this one in your practice?
Uncommonly as my personal stroke rate with CEA is well less than 1%
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