MAT# 18659106
A 59-year-old woman with a history of hypertension, hyperlipidemia, coronary artery disease status post coronary stent placement, aortic stenosis, systemic lupus erythematosus, hypothyroidism, and prior traumatic subdural hematoma status post craniotomy and middle meningeal artery embolization had a known unruptured right paraclinoid internal carotid artery aneurysm.
Before an elective endovascular aneurysm treatment on July 9, 2025, she was on chronic dual antiplatelet therapy for her prior coronary stent: aspirin 81 mg daily and clopidogrel 75 mg daily. In pre-procedure holding, an aspirin platelet function assay was 555 ARU, interpreted as subtherapeutic platelet inhibition, and she received an additional 325 mg dose of aspirin prior to the procedure. Clopidogrel was continued.
On July 9, 2025, she underwent an elective right ICA pipeline flow diverter embolization of the unruptured paraclinoid aneurysm under general anesthesia. The operative report states she was systemically anticoagulated with intravenous heparin to a therapeutic activated clotting time (ACT). The pipeline device was deployed with adjunctive balloon angioplasty. Estimated blood loss was 25 mL, and no intraprocedural complications were documented.
Post-procedure, she remained on DAPT to maintain patency of the newly placed intracranial stent. Initially, the regimen was aspirin 325 mg daily plus clopidogrel 75 mg daily, with a plan to reduce aspirin to 81 mg daily after one month depending on follow-up platelet function testing.
Within hours of the procedure, while in an ICU setting, she developed acute painful bilateral periorbital swelling followed by sudden bilateral vision loss. Emergent non-contrast CT and CTA of the head/neck showed large bilateral superior extraconal orbital hematomas with marked proptosis and stretching of both optic nerves, consistent with orbital/subperiosteal hemorrhages causing orbital compartment syndrome. CTA confirmed the right ICA pipeline stent was in place without large-vessel intracranial occlusion.
Ophthalmology documented markedly elevated intraocular pressures (approximately 70 mmHg in both eyes) with painful bilateral vision loss. Emergent bilateral lateral canthotomies and cantholyses were performed at the bedside on July 9 for decompression. Despite decompression and topical/systemic pressure-lowering therapies, she continued to have orbital/ocular bleeding, required multiple transfusions for acute blood loss anemia and thrombocytopenia, and was later found to have bilateral central retinal artery occlusions on examination.
Hematology evaluated ongoing bleeding in the setting of DAPT and a history of lupus and remote childhood immune thrombocytopenia. Workup (including coagulation studies, von Willebrand testing, platelet function analysis, antiphospholipid testing, and heparin-induced thrombocytopenia testing) did not identify an alternative coagulopathy. Neurosurgery and hematology recommended continuing DAPT due to the newly placed intracranial pipeline stent and concern for in-stent thrombosis and stroke; aspirin was maintained at 325 mg daily initially and later reduced to 81 mg daily when platelet function testing showed adequate effect.
Despite stabilization of blood counts, closure of the canthotomy sites on July 12, and improved intraocular pressure control, vision did not recover. Multiple services documented that meaningful visual recovery was not expected. She was discharged on July 15, 2025 with diagnoses including bilateral orbital hemorrhage, ocular hypertension, bilateral ocular hemorrhage, and bilateral vision loss, with no light perception bilaterally. The outcome was permanent bilateral blindness.
Looking for opinion from NS standpoint on SOC intra and post operatively. Questions welcome.
Files:
Q: How large was the unruptured anuerysm?
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Q: Where was the 25ml of blood loss from? Intracranially or at catheter access site (femoral/radial artery)?
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Q: Were her eyes taped shut during the procedure? What position was she in during the procedure? Was the procedure prolonged to a significant degree??
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Q: What was the PRU?
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Do you believe there might have been medical error?
Orbital hematomas are not a common complication of endovascular stenting. There are rare case reports of this, the first one reported in 2004 (https://www.ajo.com/article/S0002-9394(04)00553-7/abstract). This region is wholly separate from where the stent was placed and the pathophysiology of this entity is still not well understood. Bilateral hematomas is even less common. This was promptly diagnosed and addressed by the treating team, albeit with a less than favorable outcome.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Unless it can be demonstrated that there was some ocular trauma (positioning, taping etc) during the procedure, there is unlikely to be causation in the scenario.
What makes you a good expert for this case?
I am a fellowship trained, triple board-certified Vascular and Neurocritical Care Neurologist with a decade of clinical experience in inpatient/outpatient, Neuro ICU and telemedicine settings at JC-certified Comprehensive Stroke Centers.
How often do you encounter cases similar to this one in your practice?
I have never encountered a case like this, this case is worth writing up for a journal.
Do you believe there might have been medical error?
The patient appeared to have followed a perioperative clearance scheme where she was evaluated for this type of elective neurosurgical intervention.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There appear to be no deviations from standard care. The patient was evaluated perioperatively and cleared for this type of surgery. The physician evaluated and optimized the medical variables that were required to perform this highly risky
What makes you a good expert for this case?
Expert Experience and Case Review Clinical Background I have more than 20 years of experience treating patients with acute and chronic neurological injuries that arise from traumatic events, neurovascular insults, and neurodegenerative diseases, including complications from stenting procedures. In my current practice, I frequently manage cases involving ischemic and hemorrhagic strokes as well as the complications that follow these events. My extensive background ensures a comprehensive understanding of the standard of care required for stroke patients. Additionally, I possess the expertise necessary to evaluate and interpret the mechanisms of injury and causation in such cases. Case Review Experience I have previously reviewed several cases involving stroke, ich, and complications from neurosurgical procedures that resulted from invasive procedures
How often do you encounter cases similar to this one in your practice?
clinically unusually, ther eis a risk inherent to these procedures
Do you believe there might have been medical error?
Unclear what the PRU was (plavix level) but orbital bleeding bilaterally from DAPT is extremely rare and unpredictable. I do not think the extra ASA would have contributed. The DAPT is essential for the PED I would need more details to say for sure re the bleeding (PRU, doses, etc)
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Hard to tell from info but seems to follow standard platelet testing procedures for pipeline.
What makes you a good expert for this case?
I have written extensively on pipeline. I have performed over 200 in my career and am very familiar with DAPT testing.
How often do you encounter cases similar to this one in your practice?
We have >1000 cases in our pipeline database and I have not seen this.
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