The case involves a delay in diagnosis of anterior communicating aneurysm with intracrebral hemorrhage.
The patient was a 62 year old female who was taken by EMS from her home to a community hospital for headache of one hour and neck pain. She had a known history of hypertension and was a smoker. The emergency department providers did not document complaints of headache that were noted by EMS and instead worked up the patient's neck pain. Patient's glasgow coma scale was 15.
The patient arrived to the emergency department at 8:14 pm. At 2:44 am, a CT of the head, without contrast, was performed due to altered mental status that showed 6.8 x 3.5 cm left frontal/temporal acute subcortical intraparenchymal hematoma, 3.2 x2. 7 cm left anterior frontal acute subcortical hematoma, and 5.4 x 1.6 cm acute cavum septum intra ventricular hematoma as well as a 7.2 mm midline shift. The patient's glasgow coma was 10 and then later noted to be 8.
A CTA was ordered to rule out an aneurysm. The radiolgist identified an acute intraparenchymal hemorrhage in the left temporal lobe and left frontal lobe region with intraventricular blood in the third ventricle. subarachnoid blood products are also
seen in the suprasellar cistern, the right temporal lobe and the left temporal lobe region. This results in mild rightward midline shift with early subfalcine herniation and mild effacement of the fourth ventricle.
However, the radiologist failed to see an aneurysm.
As a result, the patient was sent to another facility that did not have vascular neurosurgical services. At this facility, the on-call neurosurgeon reviewed the CTA and identified an aneurysm on imaging. For this reason, the patient was then sent by helicopter to another facility with appropriate neurosurgical services. Her glascow coma scale was 3.
At 15:00, the patient underwent a left craniotomy and complex anterior communicating artery aneurysm clipping with left temporal ICH evacuation. The surgery occurred 19 hours after the patient arrived at the first hospital. The pre-operative CTA identified a 2 mm saccular aneurysm at the right carotid terminus near the origin of the PCOM with an inferiorly projecting 7 mm saccular aneurysm that appears to originate from the anterior communicating artery on the right. Probable 2 mm saccular aneurysm
extending from the left A-comm.
The question is whether earlier surgical intervention would have made a difference in a patient who now suffers memory loss, difficulty walking, incontinence due to forgetfulness, and lives in a memory unit of an assisted living facility.
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Do you believe there might have been medical error?
There were multiple errors in this case due to the initial ER’s failure to recognize and document the patient’s reported headache—a red flag for subarachnoid hemorrhage—and the delay in obtaining a CT/CTA. Almost no one is transported by EMS for neck pain, and only 1-2% of headaches are severe enough to requiring EMS transport. 1. The CT was finally performed nearly 7 hours after arrival, it revealed large, multilobar intracerebral and intraventricular hemorrhages with midline shift and signs of herniation. 2. The initial radiologist failed to identify an 7 mm aneurysm, leading to transfer to an inappropriate facility without vascular neurosurgical capability. The sensitivity of CTA for aneurysm over 3 mm in size is 98%! No excuse to miss it. Radiologist expertise and image quality significantly influence CTA accuracy but in this case it seems clear it was a radiology mistake rather then a CTA quality issue.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Two issues: delay in diagnosis and delay in treatment. 1. The delay in diagnosis led to profound coma (GCS 3). The surgery for definitive treatment was done 20 hours post-presentation during which the patient deteriorated neurologically (GCS 15 to 3). 2. The delay in aneurysm clipping and hematoma evacuation likely contributed to her poor neurological outcome, including severe memory loss, impaired mobility, and cognitive decline requiring institutional care. For ruptured aneurysms with ICH earlier intervention (<12 hours) is optimal. Delays in treatment (19-hour delay with deterioration to GCS 3), is associated with worse neurological outcomes and higher mortality.
What makes you a good expert for this case?
I am a board-certified neurosurgeon with fellowship training in cerebrovascular surgery (aneurysm clipping) and current experience taking call in stroke and trauma centers where these cases are commonly encountered. I have reasonable experience in depositions and court proceedings, and ability to communicate medical information to lay audiences in a clear manner.
How often do you encounter cases similar to this one in your practice?
I encounter roughly 10 cases per year which are ruptured aneurysms with ICH. The incidence of aneurysmal SAH in the general U.S. population is about 6–10 cases per 100,000 people per year. Therefore even busy ERs have low numbers, but the patterns and treatment protocols are well established.
Do you believe there might have been medical error?
Error in missing the initial aneurysm in CTA-
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The neurological sequela seems to be related to initial subarachnoid and intraparenchymal hemorrhage insult.
What makes you a good expert for this case?
My significant expertise in brain aneurysm treatment
How often do you encounter cases similar to this one in your practice?
Every week and sometimes multiple times a week
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