Neuroradiology Procedure Complications Result in Death

This case involves a seventy-three-year-old female patient admitted to the ER for sudden onset of right-sided weakness and aphasia. The patient was given tPA and then taken to neuro-interventional radiology for further intervention of an evolving stroke. The patient was found to have had a carotid occlusion on the left side that was cleared via interventional methods. The MCA was also severely occluded but attempts to approach this block resulted in a perforation. The patient suffered from a sub-arachnoid hemorrhage that led to cerebral edema and eventual death.

Question(s) For Expert Witness

1. Should this procedure have been attempted and was it within the accepted standard of care?

Expert Witness Response E-000158

Nonthrombolytic techniques, including low-pressure angioplasty of the thrombus and mechanical thrombectomy, continue to be the standard of care in cases that present like this. A variety of compliant and noncompliant balloon catheters are available in sizes of 2-10 mm to allow access to both the cervical and the primary branches of the intracranial arterial anatomy. Risks include distal embolization by fragmented thrombus and occlusion of small perforator branches of the circle of Willis. Mechanical thrombectomy devices most notably include the AngioJet and Neurojet devices. These tend to be most applicable to the large vessels of the neck. The Merci Retriever is capable of significantly greater distal access to the intracranial arterial and venous anatomy. Designed to extract clot in a state of flow arrest, the Merci device has contributed to a significant reduction in time to recanalization while reducing and often eliminating the need for chemothrombolysis and its associated risk of hemorrhagic complication.