Neurosurgery expert witness opines on subdural hematoma caused by mild brain trauma

A neurosurgery expert witness advises on cause and treatment of a subdural hematoma caused by mild brain trauma following a motor vehicle accident. This case involves a sixty-five-year-old female patient with a past medical history of hypertension, rheumatoid arthritis and asthma. The patient was involved in a motor vehicle accident when the vehicle she was in was rear ended by a pick-up truck. The patient sustained severe whiplash associated with a brief loss of consciousness. The patient was seen at a local emergency department and was released home with advice to take over the counter analgesia if the pain in her neck persisted. Three days following the accident the patient presented to her primary care physician complaining of headaches and mild nausea which began shortly after she returned home from hospital. The physician’s initial impression was that she had suffered a concussion and a mild neck strain. The primary care physician reiterated the advice that the patient had received from the physicians at the ER, to take Tylenol. She also advised that patient to return to her office in three weeks if no improvement in condition was seen. Approximately six weeks following this appointment the patient began to display signs and symptoms consistent with a subdural hematoma. The patient was taken to hospital via ambulance. A CT scan of the patient’s head was performed which revealed a 6mm mid-line shift and mass effect on the ipsilateral ventricles. The patient underwent an immediate craniotomy for decompression but continues to have residual left sided motor and sensory deficits.

Question(s) For Expert Witness

1. Should this patient have been sent for a CT right away by her primary care physician?

2. Could this have changed the outcome for this patient?

Expert Witness Response E-000572

The crux of this case is the indication for a head CT in mild traumatic brain injury. There are guidelines from the American College of Emergency Physicians published in 2008 that suggest a head CT is indicated where there is loss of consciousness and there are other factors such as age greater than 60 years-old, headache, vomiting among others. The subdural was more likely than not present at the time she was evaluated by the PCP. Therefore, a CT scan would have made the diagnosis and intervention would have been more timely with less chance for him to develop neurological deficit.