Neurosurgery Expert Witness Comments on Intraparenchymal Hemorrhage

This case involves a fifty-seven-year-old woman with a past medical history of carotid artery stenosis and transient ischemic attacks (TIA). She underwent a coronary stent placement previously and was placed on aspirin and Plavix prior to the admission. After the procedure, the patient was prescribed Effient and placed back on aspirin, then discharged later that afternoon. On the next morning, the patient awoke with left-sided hemiplegia. She presented back to the hospital, with a stroke code assessment yielding an NIH of 10, which was assessed as a moderate stroke. Non-contrast CT showed 2.5 cm x 2.5 cm intraparenchymal hemorrhage present in the right posterior frontal lobe with a small amount of adjacent subarachnoid hematoma. Labs showed PTT and INR of 9.4 and 0.83 respectively. A neurological consult was placed and the patient was transferred to the ICU. Routine neuroradiology checks were to be conducted on an hourly basis and repeat CT scan in 12 hours. A repeat CT scan yielded enlargement of the previously seen intraparenchymal hemorrhage, which measured up to 6.7 cm x 3.8 cm. Subsequently, there was a midline shift to the left of 3mm. The lesion had increased in size, however, and there was not much documentation showing clinical deterioration. The patient was taken to the OR sometime thereafter for craniotomy and evacuation of the hematoma/clot. Postoperatively, she had a worsening left-sided hemiplegia with aphasia and dysarthria. The patient now suffers from multiple neurological sequelae from the initial cerebral insult. The patient had an acute cerebral hemorrhage that continued to expand over while the patient was being evaluated without urgency. Despite an adequate workup, the plaintiff alleged that the nonurgent management style led to significant residual side effects.

Question(s) For Expert Witness

1. What measures should be taken when a rapidly expanding intraparenchymal hemorrhage is identified?

Expert Witness Response E-006274

Intracerebral hemorrhage (ICH) is the second most common cause of stroke, following ischemic stroke. Hematoma growth, particularly within the first 24 hours, is also an independent predictor of mortality and poor outcome. Patients with spontaneous ICH should have a head CT scan within three hours of onset and follow-up head CT within 24 hours. Each 10 percent increase in ICH growth is associated with increased mortality and worse outcome. Data from a number of studies suggest that extension of blood into the ventricles and midline shift are independent predictors of poor outcome in patients with spontaneous ICH. If any of these elements listed above are present, the patient should be taken immediately to the OR for evacuation.