18-year-old female with Chiari malformation who underwent redo decompression with fourth ventricular stent placement on 10/29/24. Within hours of surgery, she developed new cranial nerve VI and VII palsies, and a postoperative CT demonstrated that the ventricular catheter was malpositioned and compressing the brainstem. On 10/30/24, she was returned to the operating room for revision of the stent. Documentation indicates intraoperative neuromonitoring was used, but the malposition required immediate reoperation to correct.
Following the revision, IP’s neurological status initially improved; however, on 10/31/24 she developed respiratory failure with pulmonary edema requiring intubation. She remained intubated until 11/8/24. A brain MRI on 11/4/24 demonstrated bilateral cerebellar and vermian infarcts with brainstem edema and mass effect. During the ICU course she also developed a left-arm PICC-associated thrombus, an extended Foley-related urinary tract infection, and required at least one PRBC transfusion for anemia and hypotension. Documentation reflects that the family was not clearly informed of the stroke until they discovered it in the chart days later.
Currently, IP is left with persistent neurological deficits including cranial nerve palsy, diplopia, gait disturbance, and functional impairments requiring ongoing therapy.
The key questions for review are: (1) whether the stent malposition reflects a preventable technical error below the standard of care or an accepted risk of this procedure, (2) whether the subsequent cerebellar infarcts and hypoxic events were causally related to the malposition, surgery, or ICU management, and (3) whether delays in recognition and treatment of pulmonary edema, stroke, and other complications deviated from accepted standards.
BOTH OP NOTES ATTACHED AS SCREENSHOTS FOR REFERENCE.
We appreciate your time and are available for more info/clarifications
Files:
Q: I need to remove the images to be able to ascertain what occurred intraoperatively
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Q: I will need to review radiology images to understand better the potential causes of the infarctions. Please see my responses based on existing data above.
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Do you believe there might have been medical error?
Based on the materials provided, including the operative reports, there is insufficient information at this time to render a firm opinion, particularly in the absence of imaging for review. However, several points can be made: 1. Technical Aspect of the Stent Placement • The operative notes clearly describe a technically challenging reoperative procedure with significant adhesions and scarring. • Fourth ventricular stent placement is recognized to carry a risk of malposition or migration, even with reasonable care. • While the postoperative CT demonstrated catheter compression of the brainstem, without reviewing the imaging it cannot be determined with certainty whether this reflects a preventable technical error or an unavoidable consequence of a very difficult surgical field. 2. Causation of Neurological Injury • It is likely that the catheter malposition contributed to the patient’s initial cranial nerve deficits and may have played a role in subsequent brainstem/cerebellar injury. • That said, the precise causal relationship between the stent malposition, subsequent cerebellar infarcts, and respiratory failure cannot be established on the present record alone. These outcomes may also reflect the overall complexity and risks inherent to reoperative posterior fossa surgery. 3. Communication and Disclosure • One of the operative notes explicitly documents that the surgeon spoke with the family immediately after surgery to review details. This weakens the allegation that there was no disclosure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I don’t have sufficient evidence here to say there was a technical error. From the operative report, it seems like this was a very technically challenging operation with extensive scar tissue. Dissection of scar tissue has a high risk of causing neurological injury.
What makes you a good expert for this case?
Board certified in pediatric Neurosugery. Chief of Pediatric Neurosurgery
How often do you encounter cases similar to this one in your practice?
5 times a year I would have a surgery like this. I have treated about 100 chiari patients over my career.
Do you believe there might have been medical error?
The question is going to be, who is responsible for which medical error. In the summary, multiple medical errors are discussed. I will suggest that the neurosurgical error(malposition of the stent) is less egregious than the other medical issues(re-intubation, infarct, infection). Very few of us perform 4th ventricular stent due to the perceived high complication rate. The reason for the stent in this case appears to be a redo Chiari. Did this patient have a syrinx? If so, that would change the equation(and make the surgery more reasonable). Here is a recent(2023) article about the use of 4th ventricular stent in the setting of Chiari and syrinx. https://pubmed.ncbi.nlm.nih.gov/36857783/ Here is another(2018) article that is similar. https://thejns.org/pediatrics/view/journals/j-neurosurg-pediatr/23/2/article-p164.xml Not included in the screen shots is EBL as well. Requiring a transfusion after a Chiari(even a redo) is rare. Is it possible they got into unexpected bleeding?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, you will have people pointing fingers at multiple specialists. There were multiple issues with the original stent placement(switching from a ventricular catheter with a diameter of 2-3mm to a lumbar catheter, which is usually a diameter of 1.5mm) that led them to change the original surgical plan. Almost half of the sentences of the operative note are discussing how much scar there was. The stent did not cause her strokes. Her medical issues did.
What makes you a good expert for this case?
Double board certified in adult and pediatric neurosurgery. Ran the Florida Center for Chiari Care for years
How often do you encounter cases similar to this one in your practice?
Chiari-several times/week Redo Chiari - monthly Redo Chiari in which I place a stent(or in a patient who already has a stent) - never. 4th ventricular stents are rare procedures, working in a difficult location.
Do you believe there might have been medical error?
Based on the few pages of operative note detail available, there was significant complexity in this Chiari operation. The significant scarring in situations like this one can obscure normal tissue planes and raise the risk of intraoperative trauma, malpositioned devices and post-operative ischemia. These would be known risks of a revision surgery like this one.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As I am not convinced an error occured, I cannot say that an error caused an injury. However, it is likely that the ischemia post-operatively was related to the operation itself, either due to manipulation, compression by the catheter, or small vessel injury/spasm.
What makes you a good expert for this case?
I have been in pediatric neurosurgical practice for more than 5 years and have significant experience with Chiari surgery and research.
How often do you encounter cases similar to this one in your practice?
At least 10 previous cases bear similarity to this one in the extensive nature of scar tissue and revision.
Do you believe there might have been medical error?
Operative reports show a thorough surgical decision making. Although I would not use a permanent catheter, I don't believe the use is a mistake but I do think the presence of such tube has contributed to repeated surgery, and potentially induced swelling in the brainstem and additional complications.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As mentioned earlier, I don't believe the use of stent is a medical error, but rather a surgical judgment due to significant scarring encountered. However I do believe the placement of the stent was the starting point for this patient subsequent repeated surgery and other complications.
What makes you a good expert for this case?
Significant experience in Chiari surgery
How often do you encounter cases similar to this one in your practice?
Redo Chiari often, but I almost never use a permanent intraventricular drain to subarachnoid space.
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