Missed Diagnosis of Subdural Hematoma Results in Brain Damage

This case involves a sixty-two-year-old male who was involved in a motor vehicle accident and sustained severe whiplash associated with a brief loss of consciousness. Three days after the accident, the patient presented to his primary care physician complaining of headaches and mild nausea. The physician’s initial impression was that the patient suffered a concussion and a mild neck strain. The plan was to have the patient take Tylenol and return in three weeks if no improvement was seen. Approximately six weeks later, the patient began to display signs and symptoms consistent with a subdural hematoma. A CT scan showed a six-millimeter, mid-line shift and mass effect on the ipsilateral ventricles. The patient underwent an immediate craniotomy for decompression but continues to have residual left side motor and sensory deficits.

Question(s) For Expert Witness

1. During the initial visit, should the emergency room have consulted a neurosurgeon before discharging this patient?

Expert Witness Response E-000572

When a patient who experienced head trauma presents with a Glasgow Coma Score (GCS) less than twelve, consider immediate neurosurgical consultation while stabilizing the patient and diagnostic maneuvers are in progress. Small, asymptomatic, acute subdural hematomas (SDHs), however, may be managed by observation, serial examinations, and serial computed tomography (CT) scanning. Operative intervention is required for patients with focal findings, neurologic worsening, hematoma greater than one centimeter thick, midline displacement or shift greater than five milimeters, or increased intracranial or posterior fossa pressure.