Allegation:
A failure to diagnose VP shunt malfunction caused permanent impaired vision.
The Case:
A 26 YOF (5’5”, 335 lbs.) presented to the ED with complaints of dizziness and facial pain that worsened with standing. Her medical history was significant for obesity, HTN, A-fib, migraine headaches, sleep apnea, depression, a permanent pacemaker for prolonged QT syndrome, and a VP shunt due to hydrocephalus from childhood. Her medications included metoprolol, Xyzal®, Neurontin®, Claritin®, Zoloft®, Singulair®, Cozaar® and Imitrex®, and Zithromycin® for a recent sinusitis diagnosis.
Upon presentation, the patient’s supine pulse was 72, and her standing pulse was 85. Her supine BP was 146/88, and her standing BP was 191/102. She was given 50 mg Antivert® without relief. The ED physician’s assessment was "facial pain; dizziness on standing, no objective cause; ongoing subacute sinusitis." He encouraged the patient to follow up with her PCP for better BP control.
Five days later, the patient presented to a different ED with complaints of dizziness and headaches for four weeks. A head CT without contrast showed evidence of a VP shunt with no interval development of hydrocephalus, mass, or bleed. The CT looked no different from one done the previous year. A shunt series showed integrity of the shunt apparatus and everything in proper position. A consulted neurologist’s funduscopic exam of the patient revealed no papilledema. A lumbar puncture showed high opening pressures of 43 cm of water. The pressure returned to normal once 35 ml of CSF was removed, which somewhat abated the patient's headaches. The neurologist ordered Diamox® for the patient, and she was discharged.
The patient returned to the ED a few days later complaining of a throbbing headache. The same neurologist from the patient’s previous ED visit saw her and recommended outpatient follow-up. Since she was unable to ambulate, the patient was admitted. The next day, the defendant neurosurgeon examined the patient on a consult request. He noted the patient was awake, alert, oriented, and in no acute distress, with cognitive function within normal limits. He also noted she was able to converse and follow commands properly, with no abnormalities of her extraocular motor function, no gross visual field defects, and no diplopia. Because the head CT had not changed after more than a year and the shunt series showed the shunt intact, the defendant neurosurgeon did not believe the patient’s headaches were caused by a shunt malfunction.
The defendant neurosurgeon recommended treating the patient medically with a presumptive diagnosis of a pseudo tumor cerebri. He also recommended a neuro-ophthalmological evaluation and a repeat head CT scan to compare with the most recent scan. He documented that he did not plan to see the patient again unless there was another consultation. The defendant neurosurgeon had no further involvement with the patient. A repeat head CT showed the ventricles, sulci, and cisterns were within normal size and configuration, with no intra-cranial hemorrhage or mass effect identified. The patient improved and was discharged with a diagnosis of headache, likely secondary to pseudo tumor cerebri.
A few days after discharge, the patient presented to another facility ED with complaints of headache, lower back pain, and decreased visual acuity. She reported recent falls due to changes in her vision. Her visual acuity measured 20/200 when tested, but when instructed to read the Snellen chart at two feet from her face, she could read to 20/30 with no difficulty or squinting. She was discharged in stable condition.
Several weeks later, the patient was admitted with complaints of headache, nausea, and vomiting. She was diagnosed with papilledema. A head CT scan compared to earlier studies showed subtle ventricle enlargement. A shunt series showed the shunt disconnected at the level of the upper abdomen. The patient developed intermittent seizures in addition to her headaches. A neurosurgeon performed a laparoscopic shunt replacement, and a post-op head CT scan showed stable ventricle size with no evidence of intracranial hemorrhage. The patient suffered no post-operative seizures. An ophthalmologist who saw the patient on an outpatient basis after discharge diagnosed her with bilateral optic neuropathy.
The patient sued the defendant neurosurgeon who recommended only medical follow-up, claiming he failed to evaluate her properly, did not perform a funduscopic eye exam, and failed to detect that her VP shunt was malfunctioning. A plaintiff’s expert testified the defendant neurosurgeon was negligent for failing to order a shunt-o-gram, which would have shown the shunt was malfunctioning. The defense countered that the shunt failure occurred after the defendant saw the patient, because the shunt series performed prior to the defendant neurosurgeon’s interactions with the patient was normal.
Verdict:
The case went to trial, and the jury returned a unanimous defense verdict.
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