MAT#17590812
This matter involves a 19-year-old male with developmental delay and a longstanding ventriculoperitoneal shunt placed in infancy, who died on March 19, 2025, three days after discharge from the hospital. In the week preceding his death, he presented twice for evaluation of headache, neck pain/torticollis, and concern for possible VP shunt obstruction versus meningitis. At the March 12, 2025 emergency department visit, CT imaging was reviewed and the record reflects that neurosurgical input was obtained, with the determination that he could be managed on an outpatient basis without immediate neurosurgical intervention.
He returned on March 14, 2025 with ongoing symptoms and was admitted for further evaluation. During that admission, neurosurgery assessed him for possible shunt malfunction and performed a right parietal VP shunt tap. The neurosurgical documentation states there was good spontaneous flow from the proximal shunt, while also noting that valve or distal catheter malfunction remained possible, and that shunt revision would be deferred pending continued monitoring. During the hospitalization, he was also treated with antibiotics and evaluated for possible meningitis. The records indicate that after observation and treatment, neurosurgery documented that he was clinically improving and that suspicion for acute shunt malfunction was relatively low, and he was discharged on March 16, 2025.
On the morning of March 19, 2025, he was found unresponsive and suffered a fatal arrest. Autopsy findings included cerebral edema; status post remote VP shunt placement with dilated cerebral ventricles and cerebral aqueduct causing compression of nearby structures; congested meningeal and epidural vessels; a membranous cyst at the base of the brain; pulmonary and hepatic congestion; bilateral pleural effusions; mild glomerular and tubular nephritis on histology; mild chronic kidney disease; constipation with impacted feces in the rectum compressing the bladder; abdominal adhesions; no evidence of infection or malignancy; and CPR-associated rib fractures. (see attached for reference)
The questions for expert neurosurgical review are whether the assessment and workup during the March 12 and March 14 encounters were adequate to evaluate for shunt-related dysfunction, whether additional testing or intervention should have been performed in light of the clinical presentation and imaging findings, and whether the decision to monitor and discharge rather than proceed with further shunt evaluation or revision played a substantial role in the patient’s death.
Thank you for your thoughts and questions welcome.
Files:
Q: What imaging was performed?
A: —
Q: Are imaging reports and vp shunt tap note available?
A: —
Do you believe there might have been medical error?
Need more info about patient's baseline ventricular size and morphology, and etiology of HCP. Has the shunt failed in the past and if so did ventricles increase in size? Proximal flow on a shunt tap does not always indicate proximal function - there can be residual fluid in the valve. Given this patient's repeat presentation I would have done a proper shunt exploration in the OR to r/o failure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It sounds like this patient died from hydrocephalus, which is most likely from shunt malfunction, which was not fully ruled out in the workup.
What makes you a good expert for this case?
I am a dual boarded pediatric and adult neurosurgeon with specialty experience in complex hydrocephalus with a range of etiology.
How often do you encounter cases similar to this one in your practice?
Almost daily - I was trained in one of the top centers for pediatric hydrocephalus - congenital, IVH related, and spina bifida. We saw many many patients with complex shunt systems and failures where ventricular size did not increase on imaging.
Do you believe there might have been medical error?
Workrkup was adequate per basic standards but potentially insufficient pending more information regarding shunt tap, imaging and symptoms.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Likely contributory, possibly substantial, but causation is probabilistic rather than certain without full record review
What makes you a good expert for this case?
Chief of pediatric neurosurgery with more than a decade experience in the treatment and management of hydrocephalus
How often do you encounter cases similar to this one in your practice?
on a daily basis I encounter cases similar to this patient
Do you believe there might have been medical error?
The key is going to be who actually saw the patient and what imaging he had. 19yo is a no man's land, transitioning from pediatric to adult neurosurgery. Was he seen by an adult neurosurgeon, with whom he no relationship and had no comparison images? What did his admission/ER imaging reveal? The autopsy discusses revealed dilated ventricles. Did his pre terminal imaging confirm that? Routine work-up for a patient in shunt failure is a head CT and shunt series. He almost certainly had those images(probably with each admission). >80% of the time, head CT will confirm dilated ventricles. did they have comparison images(were his ventricles smaller, larger, or the same compared to times when he was asymptomatic)? Shunt tap is a good test. They confirmed proximal flow. We would routinely document an opening pressure as well(what was his intracranial pressure at the time of the shunt tap?). Normal pressure reduces the risk of shunt failure. Elevated pressure means he needs to go to surgery for shunt exploration/revision. His developmental delay complicates his clinical evaluation. Family always knows these kids better than any clinician. Look at the records. Make sure the attending neurosurgeon actually saw this patient(not just the PA or resident).
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes. He died of shunt failure, confirmed by autopsy. This is the easy part. The more difficult part is confirming the neurosurgeon missed the diagnosis, as discussed briefly above.
What makes you a good expert for this case?
At a minimum, you want someone who frequently deals with similar issues. I would strongly suggest an expert who is board certified in pediatric neurosurgery. That list can be found at www.abpns.org. I practiced in Orlando for about 25 years(no longer there). We had similar cases several times a week. Orlando is the most common destination for make a wish. This work-up is life or death. I have 30+ years pediatric neurosurgical experience, while maintaining a foot in adult neurosurgery(board certified in adult and pediatric neurosurgery), taking call at our adult Level I trauma center and our free standing pediatric hospital.
How often do you encounter cases similar to this one in your practice?
weekly. This is the bread and butter of pediatric neurosurgery.
Do you believe there might have been medical error?
This patient clearly died of acute hydrocephalus due to shunt malfunction. Two visits in the ER with the same symptoms are quite concerning. Not sure what was the degree of hydrocephalus on CT, but just a shunt tap is not enough. If needed shunt series, nuclear medicine tracer test to check patency, and eventually just a shunt exploration and revision in patient w abnormal CT and persistent symptoms should be considered. Some details on initial evaluation re detailed CT findings and additional test performed(if any) would be helpful.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Lack of thorough assessment of shunt dysfunction, and lack of urgent attention for consideration of a possible revision.
What makes you a good expert for this case?
This is a general neurosurgery case. Any neurosurgeon should know how and when to deal with a dysfunctional shunt in a patient who is shunt dependent. It is basic.
How often do you encounter cases similar to this one in your practice?
I am a sub-specialized neurosurgeon but will still see about 5-10 patients with suspicion of shunt dysfunction in the ER every year and some necessitate urgent revision.
Do you believe there might have been medical error?
The workup seems thorough with a shunt tap, etc. The question is whether they did imaging of his head (CT) and of his abdomen. Also would need to do a shunt series to make sure no breaks distally.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again it depends on the workup. Constipation can cause distal malfunction due to increased abdominal pressure but it would be rare for it to cause overt failure. Sometimes a shunt tap can clog a shunt proximally but the tap sounds indicated. I would need to know results of CSF studies for infection, CT scan of head, CT abdomen, and shunt series.
What makes you a good expert for this case?
I perform 30 shunt surgeries a year. I also see many pediatric shunts who graduate to adulthood.
How often do you encounter cases similar to this one in your practice?
It is a very common ED consult
Do you believe there might have been medical error?
Evaluation of patients with longstanding shunted hydrocephalus can be challenging, and this patient's presentation and story suggest that he may not have compliant ventricles. Imaging would be helpful for review in this case. The team appropriately tapped the shunt and monitored in the inpatient setting when the diagnosis was uncertain. It is possible that the clinical improvement was due to the shunt tap rather than a functioning shunt, but because they observed for 2 days before discharge I would expect that an obstructed shunt would have declared itself in that time. It is possible that the shunt actually malfunctioned after the patient was discharged, and was functioning during the admission. In my review of this case the team took the appropriate steps to evaluate the shunt. I say this with the caveat that further information/records from the case would help more deeply evaluate this question.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I do not believe there was a medical error, and so there is not causation
What makes you a good expert for this case?
I practice pediatric neurosurgery in an academic medical center and take care of a large number of patients with hydrocephalus.
How often do you encounter cases similar to this one in your practice?
I see patients like this multiple times per month.
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