Patient is 5'3", weight: 182lbs
Neck pain and headache started 9-23.
Chiropractor visit 9-25:
• Pain is a 9/10. Occiput pain radiating into the head.
Chiropractor visit 9-28:
• Same complaint.
Chiropractor visit at new location 10-1:
• She reports currently having headaches, neck pain, stiff neck, sleeping problems, back pain, tension, shoulder/neck/arm pain, pins and needles in arms and legs, weakness in arms, lights bothering eyes, ears ringing, buzzing in ears, and shoulder pain. She reports previously having high blood pressure.
• At this visit, she hand-writes “blurred vision in left eye”. The chiro also writes this.
• The chiro notes that she had this same issue in 2016: blurred vision and neck pain.
• Chiro recommended seeing an ophthalmologist.
• On 10-2-21, the chiro notes he called the patient to see if she spoke with the ophthalmologist and she said she had an appointment for next week.
Orthopedic visit 10-4:
• She is seen by the NP-C and reports the same neck pain and blurry vision in left eye.
• She has an x-ray of her neck which is not concerning.
• The NP recommends she go to the ER if her vision gets worse. The NP also gives a referral for neurology and recommends she see an ophthalmologist.
Hospital visit 10-6 to 10-16:
10-6
• Admitted at 1206 on 10-6 to the ER reporting blurred vision in her left eye for 1 week, and some decreased vision in right eye.
• An ED provider performs a fundoscopic exam, which is negative.
• CT Angiogram Brain/Head and CT Angiogram Neck with contrast at 1500 on 10-6 (see report).
• Patient is diagnosed in the ER with idiopathic intracranial hypertension.
• NP orders a consult to Neurology at 1702.
• Patient is given 40mg of Lovenox at 2326.
10-7
• MRIs of brain and neck at 0238 on 10-7 (see report).
• Neurology consult at 1012 where he orders a lumbar puncture.
• The lumbar puncture is performed at 1257. The patient’s opening pressure is greater than 55 cm water. They removed 30 mL of CSF.
• A CT without contrast is performed at 1643 (see report)
• The patient is given her first dose of 500mg of Diamox at 1655 and orders are for her to have 500mg BID.
10-8
• Patient is having fluctuation in her vision. She reports that the previous evening she could see her phone better, but in the morning her vision is less clear.
• MD at bedside at 0928. He discussed continuing treatment with Diamox and that it will “take some time to show significant improvement”.
• MD reports that OT is getting ready to see the patient to help her adapt to her current visual impairment.
• Patient starts to have left-sided weakness and is taken for MRI at 2336 that shows an acute infarct in the right cerebellum (see report).
10-9
• At 0843, the patient is taken for a CT Angiogram and CT Venogram (see report).
• At 1450, the patient is started on Heparin.
• Patient is transferred to Neurology.
10-11
• Patient’s vision status is noted as “Blind”.
• Neurology notes that there is no need for a repeat lumbar puncture at this time due to patient’s worsening vision after her 1st LP, and he does not wish to hold anticoagulation.
10-12
• Patient can see shadows from her right eye.
10-14
• Ophthalmology consult: “Discussed very very guarded visual prognosis. Refer to neuro-ophthalmology/oculoplastics, but discussed high risks of ON sheath fenestration, especially in the setting of anticoagulation. Recommend continuation of anticoagulation, Diamox, and encourage weight loss, and investigate etiology of stroke/hypercoagulable workup.”
Patient is discharged on 10-16. She remains fully blind in both eyes after completing various treatments.
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Do you believe there might have been medical error?
Based on the sequence of events I am uncertain as to what happened. It would be highly unusual for IIH to cause a stroke. Perhaps she had a dissection as a result of chiropracty? Further records and imaging are required to sort this out.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Same answer as above. Based on the sequence of events I am uncertain as to what happened. It would be highly unusual for IIH to cause a stroke. Perhaps she had a dissection as a result of chiropracty? Further records and imaging are required to sort this out.
What makes you a good expert for this case?
I am a board certified neurologist and neurocritical care physician at an academic medical center. I have authored over 100 peer reviewed articles on neurological diseases. I have served as an expert on several prior cases and have provided live trial/deposition testimony for both the defense and plaintiff. Please see my CV for further information.
How often do you encounter cases similar to this one in your practice?
I am a hospital based neurologist at an academic medical center. I take care of complex and high-risk patients such as this on a daily basis.
Do you believe there might have been medical error?
In retrospect the patient's presentation makes more sense for acute venous sinus thrombosis rather than idiopathic intracranial HTN.. If this was suspected at the initial 10/6 visit anticoagulation would likely have been started sooner which may have reduced the risk of thrombosis propagation that happened later in the hospitalization.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is possible that starting anticoagulation on presentation on 10/6 instead of 10/9 could have lessened the risks of clot propagation, but this can happen even despite appropriate and timely anticoagulation.
What makes you a good expert for this case?
I have over a decade of experience with neurovascular diseases and disorders. It's the primary focus of my current clinical work.
How often do you encounter cases similar to this one in your practice?
Commonly, likely 4-5 per year on average over the past ten years
Do you believe there might have been medical error?
It is unclear what happened but it is not as simple as blaming Idiopathic intracranial hypertension as a cause of the blindnes especially in tbe absence of papilledema. The elevated opening oressure could be several things and is nonspecific. Overall I wpuld say the picture is not clear. The only objective finding is the stroke which doesn't occur w IIH. I wonder if the chiropractor dissected a vertebral artery? Reviewing the imaging can help elucidate whetger this is impact a dissection or truly a cerebral venous sinus thrombosis. If there is thrombosis then a CTV should have been obtained and anticoagulation initiated earlier.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is unclear what happened but it is not as simple as blaming Idiopathic intracranial hypertension as a cause of the blindnes especially in tbe absence of papilledema. The elevated opening oressure could be several things and is nonspecific. Overall I wpuld say the picture is not clear. The only objective finding is the stroke which doesn't occur w IIH. I wonder if the chiropractor dissected a vertebral artery? Reviewing the imaging can help elucidate whetger this is impact a dissection or truly a cerebral venous sinus thrombosis. If there is thrombosis then a CTV should have been obtained and anticoagulation initiated earlier
What makes you a good expert for this case?
I am a triple trained neurologists, neurointensivist and neuroendovascular surgeon at a quarter nary care center.
How often do you encounter cases similar to this one in your practice?
This is a challenging case and it is unclear what the underlying cause of the blindness is however practicing at my comprehensive stroke center allows .e to serve a large area with almost 4 million inhabitants. This allows me to manage large numbers of rare cases.
Do you believe there might have been medical error?
Blindness from IIH can usually be prevented. Ending up blind in both eyes is a terrible outcome. There are treatments for IIH, and they usually can prevent blindness.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This question assumes that there was a medical error. To answer the question, I would need to know what medical error is assumed and to review the records.
What makes you a good expert for this case?
I have cared for IIH patients, and I have been an expert witness in IIH cases, including one case very similar to this one.
How often do you encounter cases similar to this one in your practice?
IIH is not a common illness. I have seen at least a dozen IIH patients.
Do you believe there might have been medical error?
This is an unfortunate outcome for the young woman who is now experiencing severe impairment of vision in both eyes. Based on the available information, it appears that vision loss in both eyes is the result of papilledema (optic disc swelling due to elevated intracranial pressure) and that the elevated intracranial pressure was the result of cerebral venous sinus thrombosis. -- the chiropractor asked her to see an ophthalmologist -- the nurse practitioner in orthopedics placed referrals to both neurology and ophthalmology and advised she report to hospital if vision worsens -- in hospital she had all the appropriate investigations, including lumbar puncture, for elevated intracranial pressure and these occurred in a timely fashion -- management including lumbar puncture, acetazolamide, and anticoagulation with heparin were all appropriate -- an argument can be made that a cerebrospinal fluid diversion procedure (such as ventriculoperitoneal shunt) or transverse sinus stenting could have been performed during the hospitalization, but that would not necessarily represent a standard of care and therefore not doing so would not likely constitute breach in standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Since I believe that, despite poor visual outcome, medical error did not occur, then I do not belie that there was causation.
What makes you a good expert for this case?
I have practiced as a Neuro-ophthalmologist for 9 years. I see about 50 patients weekly and have encountered the described scenario (papilledema related to cerebral venous sinus thrombosis) several dozen times, including at least six times so far in 2023. I have managed many more patients with various causes of papilledema at different levels of severity.
How often do you encounter cases similar to this one in your practice?
I have encountered the described scenario (papilledema related to cerebral venous sinus thrombosis) several dozen times, including at least six times so far in 2023. I have managed many more patients with various causes of papilledema at different levels of severity. I see at least 18 patients weekly with papilledema, including about 6 new cases per week. I have managed patients with lumbar punctures, medications, and made referrals for urgent CSF diversion procedures (VP shunt), including twice this year, most memorably in March 2023. Others have benefitted from transverse sinus stenting. Most do not need surgical management.
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