33 year old female who had history of pulmonary embolism during her pregnancy in 2011 and also is having some back pain in November of 2022 and was found to have a splenic thrombosis and small pulmonary embolisms. She was being evaluated by hematologist who put her on anticoagulation therapy. This was multiple visits over about 6 months in which she had regular blood draws including a hypercoagulable workup. Hematology had multiple changes in medication but appear to do an admirable job and balancing her INR, anemia/iron deficiency, etc.
During her course, it was noted that she admitted to missing multiple doses of medications, however full work-ups reveal no significant setbacks with her therapy. She had CTA of chest, abdomen/pelvis which revealed fatty liver disease with possible progressive liver damage. She was managed medically on this.
In July of 2023, her hematologist stated that she had no further evidence of blood clots and was going to remove her from warfarin with scheduled follow-up.
September of 2023, she's brought to the emergency room for declining mentation and multiple seizure episodes. Blood work shows normal platelets, INR and H&H. She did show positive for benzodiazepines and marijuana.
Dry CT of the head showed no acute CVA however CTA revealed acute right vertebral artery occlusion. It showed left sided reconstitution through small collaterals from the right vertebral artery.
MRI shows extensive multiple acute ischemic strokes in multiple areas of the brain and references a possible “underlying hypercoagulable state” however, her hematologist ran those diagnostics outpatient earlier in the year and they were unremarkable.
Given the cerebral injuries, neurology indicates that the brain is not survivable and any intervention would be futile.
The family removed life support and she passed on September 10th of 2023.
The family states that the clotting issues have been going on for 11 years and she should have not been removed from her anticoagulation therapy.
Need a Hematologist familiar with these type cases to find out if it was appropriate that she was removed from her Coumadin once they determined that she was not having any clotting issues post imaging. Or should she have been on them chronically?
HOSPITAL NOTES:
33 years old female with PMH of hypertension, pulmonary embolism (2011 during pregnancy), splenic thrombosis on chronic anticoagulation with Coumadin (1]12022) and anxiety disorder who presented to our hospital ED C/o severe headache and during her ED evaluation started with declining mentation and developed 2 seizure episodes requiring to be endotracheally intubated and started on mechanical ventilation for airway protection. Patient history obtained from patient's chart because patient is currently mechanical ventilated and there is no family members at bedside. Patient received LR bolus, IV lorazepam, Keppra and Dilantin on ED and was transferred to ICU for further treatment and evaluation. She was already evaluated by critical care team and started on IV antibiotics to cover the possibility of CNS infection. She is currently endotracheally intubated on mechanical ventilation and sedated on propofol drip. Patient was hemodynamically stable on arrival but noted hypertensive with BP 165/85, pulse 60 respirations 22, temperature 97.6° and 02 saturation 100%, on room air. Labs on arrival: ABGs: 7.33/44.6/71.6/24. Six. Normal lytes and renal function. Random blood sugar 134 mg/dL Normal LFTs. Troponin noted elevated 100>> 176. EKG: Sinus rhythm 72. No acute ischemic changes. WBC 21 K. segs 87% H&H 12.2/37. Normal platelet. H&H 12/37.5 INR 0.92. Phenytoin level less than 0.8. UA negative for U11. Drug screening positive for benzodiazepine and cannabinoids. CT head without contrast: Negative for acute CVA. lndeterminated focus of Left occipital lobe attenuation place developing infarct and posterior reversible encephalopathy syndrome in the differential. Chest x-ray: Pulmonary congestion.ITT close to carina. CTA neck: Suspected right vertebral artery occlusion. CT head with IV contrast: No enhancement of hypoattenuation seen on left occipital lobe.
MRI RESULT
MRI brain was reviewed and did show extensive multiple acute ischemic strokes in multiple areas of the brain ,pt probably has underlying hypercoagulable state, unfortunately given these massive strokes this is not survivable brain injury, any Neurological or Neurosurgical intervention would be futile at this point
Thank you in advance
Files:
No questions yet!
Do you believe there might have been medical error?
I am not convinced there was a medical error here. Pregnancy places women at a very high risk for thrombotic events. Not all women who have a pulmonary embolism during pregnancy require life-long anticoagulation. If she had a negative work-up for a hypercoagulable state, since the pulmonary embolism was provoked (by pregnancy) it would be reasonable to stop anticoagulation and observe. It would be very unusual for an individual to have a hypercoagulable state so severe as to cause both pulmonary embolism and multiple fatal thrombotic strokes, so it is not clear from the data presented that these two events have the same cause. The exception might be antiphospholipid syndrome. If I were reviewing this case for litigation, I would want to see if she were tested for that condition. I would want to review what exactly happened during pregnancy when she had the pulmonary embolism and what happened from 2011 - 2023. Was she off of anticoagulation for any extended periods of time? I would want to see what transpired to make the family think that "the clotting issues have been going on for 11 years and she should have not been removed from her anticoagulation therapy." Just because the patient was anticoagulated does not mean that there were ongoing clotting issues. However, would want to know more about when the splenic vein thrombosis occurred and whether she was on or off anticoagulation. I would want to know whether she was mostly therapeutic on her warfarin or sub-therapeutic from 2011 - 2023. Finally, I would want to know whether her drug use included any agents that can cause vasculitis, such as cocaine and whether she had ever been evaluated for an atrial septal defect that could allow systemic clots to travel to the brain.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above discussion. See above discussion.See above discussion.See above discussion.
What makes you a good expert for this case?
I have been practicing clinical hematology for 35 years, including making decisions about who stays on life-long anticoagulation and who comes off.
How often do you encounter cases similar to this one in your practice?
Every week. Every week.Every week.Every week.Every week.Every week.Every week.Every week.
Do you believe there might have been medical error?
Here, her PE could be from the hypercoagulable state of pregnancy. Why did she also have splenic thrombosis? Did they do a PNH clone testing evaluation? It is idiopathic thromboembolism and she should have been kept on anticoagulation. It is possible that in 2012, it was not tested. Nevertheless, she should have been kept on lifelong anticoagulation as she has no inciting factors for her thrombosis and PE.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
We do not have a good understanding of her splenic vein thrombosis, which increased her risk for clots. Her PE could be from her pregnancy.
What makes you a good expert for this case?
I have done depositions and testified at trial.
How often do you encounter cases similar to this one in your practice?
Not seen commonly except in one case.
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