Delayed Diagnosis of Cerebral Hemorrhage Leads to Neurological Defects

This case involves a 36-year-old pregnant woman who had experienced debilitating headaches throughout her pregnancy. She was admitted to the hospital due to preeclampsia. Prior to the delivery, the patient continued to have excruciating headaches. The patient had a normal delivery, after which her headaches began to subside. After almost 48 hours in the hospital, the patient’s headaches appeared stable. No imagining was conducted and the patient was discharged. The following night, the patient developed slurred speech and intense headaches while at home. The patient’s husband brought her back to the emergency department and imaging revealed a cerebral hemorrhage and venous sinus thrombosis. The patient was initiated on anticoagulation and required a decompressive craniectomy, which caused the patient persistent neurological deficits.

Question(s) For Expert Witness

1. How frequently do you treat patients with venous sinus thromboses?

2. If the thrombosis had been identified and treated earlier, how would the prognosis have changed?

Expert Witness Response E-036010

Our neuroscience ICU, in which I am an attending physician, admits approximately 4-7 cases of cerebral venous thrombosis (CVT) every year. The diagnosis is in the differential for many more women we see with acute headache and neurological signs and symptoms. Some of these patients require mechanical thrombectomy in the interventional radiology suite in addition to anticoagulation. I also consult on women with headaches, seizures, and focal neurological deficits in our OB-GYN wards as a neurocritical care specialist. Early diagnosis is, of course, paramount to management, since this is a syndrome which is particularly responsive to anticoagulation with heparin and early therapy may ameliorate neurological deficits. The index of suspicion for CVT should be high in the peri-partum period in women. Head CT may be normal, but MRI with MRV is very sensitive to diagnosing the problem. Heparinization, in the setting of CVT, can prevent thrombus propagation and potentially gives the patient a better chance of avoiding hemorrhage expansion, and cerebral edema, which, as may have happened in this case, leads to the need for decompressive craniectomy to prevent herniation.