Failure to diagnose and treat dissection of the carotid artery

Presentation
A 35-year-old woman delivered her third child and was discharged from the hospital two days later. Her pregnancy had been complicated by preeclampsia and gestational diabetes. On January 29 — six days postpartum — she came to the emergency department (ED) with a severe headache in her occipital and frontal regions and pain in the back of her neck. The patient had taken ibuprofen, acetaminophen, and butalbital/acetaminophen without any relief.  

 

Physician action
The patient reported the head and neck pain as 10 on a 10-point pain scale. Her blood pressure was also elevated. The patient’s ob-gyn suspected a muscle spasm headache. However, due to the persistence of symptoms, the ob-gyn admitted the patient for treatment of her symptoms and for lab tests for preeclampsia. 

During her hospital stay, the patient was treated with carisoprodol and hydrocodone for her headache. She reported an improvement to 5 on a 10-point pain scale. The patient also reported that the pain in her neck was still present and had not improved.

At the request of the patient’s husband, a neurologist saw the patient on January 31.

The neurologist noted that the neck pain and headache were most likely of musculoskeletal origin. He agreed with continuing methocarbamol, butalbital/acetaminophen, and hydrocodone as needed for pain.

The neurologist also recommended the use of a heating pad and gentle, passive neck exercises. The neurologist advised the patient that he would consider doing x-rays of her cervical spine if the headache persisted. The patient was discharged.

Three days after her discharge, the patient collapsed at home. EMS brought the patient to the ED. She was dysarthric with a possible right-sided droop. That night in the hospital, the patient developed right-sided hemiplegia with the inability to move her right leg and arm. She was diagnosed with an acute left middle cerebral artery CVA with complete occlusion of the left internal carotid artery and dissection of the right internal carotid artery.

Following her hospital stay and therapy, the patient was still experiencing right-sided weakness, along with memory and cognition difficulties.

 

Allegations 
A lawsuit was filed against the neurologist. The allegations included:

  • failure to properly and timely diagnose and treat dissection of carotid artery;
  • failure to order anticoagulation therapy; and
  • failure to properly and timely diagnose and treat pregnancy-induced hypertension and severe preeclampsia.

The patient’s ob-gyn was also sued.


Legal implications  
Plaintiff’s experts were critical of the neurologist for not ordering neuroradiological studies before discharging the patient. Given the severity of the patient’s headaches, neck pain, preeclampsia, and postpartum circumstances, an MRI study, at a minimum, was warranted.

Although the defense experts who reviewed this case agreed that the standard of care required a CT or an MRI study, it was noted that possible complications of pregnancy were not accounted for or noted by the neurologist. The majority of the consultants who reviewed this case felt that under the circumstances, an MRA should have been ordered. An MRA would have detected the dissection and led to treatment and prevention of a stroke. The patient was discharged without appropriate brain and vascular imaging studies.


Disposition 
This case was settled on behalf of the neurologist and the ob-gyn.
 

Risk management considerations
According to a review of more than 350,000 paid claims from 1986 to 2010 included in the National Practitioner Data Bank, diagnostic errors generate more medical liability payments than any other medical error. (1)  

Being aware of the potential complications due to a patient’s medical history is important.  Consultants felt that the neurologist did not consider the possible complications of the patient’s recent pregnancy and delivery.

Consultants noted that arterial dissection was a reasonable differential diagnosis, and brain and vascular imaging studies should have been performed to exclude aneurysms and venous occlusions, and to detect and quantify any cerebral vasoconstriction. Furthermore, there was no documentation of risks and benefits discussed with the patient regarding the treatment plan and medication therapy.
 

Source
1. Tehrani SS, et al. 25-year summary of U.S. malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank. BMJ Quality & Safety. April 22, 2013. Available at: http://qualitysafety.bmj.com/content/early/2013/03/27/bmjqs-2012-001550.abstract . Accessed September 26, 2013.

 

These closed claim studies are based on an actual malpractice claims from TMLT. These cases illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. These studies have been modified to protect the privacy of the physicians and patients.

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