Failure to Diagnose Evolving Stroke Leads to Patient’s Death

This case involves a twenty-nine-year-old patient who delivered a child by cesarean section. One month after her delivery, the mother presented to an emergency room and advised the staff that she had a headache. She also complained of onset nausea and vomiting. The emergency room doctor ordered a CT-head that was interpreted busing stroke telemedicine, and was assessed to be normal. A progress note recorded that the patient advised staff that it was a painful migraine and that she was experiencing blurred vision. A decision was made to discharge the patient from the emergency room in light of the negative head CT. She was given a prescription for Topamax, but no medication or treatment was provided for the patient’s high blood pressure. Two days later, the patient returned to the hospital with slurred speech, drooling, and weakness of the upper and lower limbs. An additional head CT was immediately ordered which showed an intracranial hemorrhage. The patient was airlifted to a tertiary care center where she ultimately died of an intraparenchymal hemorrhage in the left cerebral hemisphere.

Question(s) For Expert Witness

1. What therapy would be indicated if this evolving stroke was noticed on the first CT-scan and how would this have altered the outcome?

Expert Witness Response E-000572

One should consider nonsurgical and neuroradiology management for patients with minimal neurological deficits or with intracerebral hemorrhage volumes less than 10 mL. Surgery would be indicated for patients with cerebellar hemorrhage greater than 3 cm, for patients with intracerebral hemorrhage associated with a structural vascular lesion, and for young patients with lobar hemorrhage. The common hypertensive hemorrhages in the basal ganglia have not been shown clearly to benefit from surgery, although case series with favorable outcomes after stereotactic needle evacuation or endoscopic drainage have been reported. In the past, standard craniotomy with evacuation of the hematoma did not appear to improve outcomes.