Allegation:
The failure to identify a subdural hematoma in CT imaging resulted in a treatment delay that led to cognitive deficits for the patient
The Case:
A 53 YOM (5’4”, 164 lbs.) was transported to a hospital ED by a co-worker, who reported the patient became unable to follow commands or answer questions. The patient indicated he did not know what happened. His medical history was significant for HIV, hepatitis C, and hemophilia. An emergency medicine physician evaluated the patient and admitted him with a diagnosis of altered mental status. She also ordered an EKG, CXR, and head CT.
The defendant radiologist read the head CT and reported the following: “CT scan of the brain on the patient was performed skull base to vertex without the use of intravenous contrast. The ventricles and CSF spaces are prominent, reflecting diminishable volume. No mass lesion in the brain is seen. There are no extra-axial collections. There is no acute infarct. Calvarium and orbits are normal.” The defendant radiologist’s impression was “Volume loss. No acute bleed or infarct.”
A neurologist evaluated the patient upon admission, and noted the patient was awake, alert, and oriented to person, place, and time. The neurologist further noted an assessment of normal cognitive function, and a reported episode of unclear etiology. His impression was that the patient most likely experienced a TIA. The patient had recently received intravenous immunoglobulin, which could have increased his risk for a stroke or thromboembolic event. The neurologist ordered an MRI of the brain with and without contrast, as well as an MRA of the brain without contrast. He indicated he would continue to follow the patient.
The following day, the patient’s wife reported the patient experienced several episodes of incoherence and complained of a headache. A nurse examined the patient, and found him alert, oriented, and able to answer questions three times. The neurologist was notified, but he deferred changing the treatment plan until he could review the MRI results. An internist later evaluated the patient and ordered a repeat head CT. The repeat head CT, read by a different radiologist, revealed subtle high attenuation adjacent to the left frontal lobe, likely representing a subdural hematoma, but no significant changes from prior examination.
The MRI revealed no significant changes in the size of the extra-axial fluid collection in the left frontal convexity. It continued to measure 5 mm with an impression of subdural hematoma of the left frontal convexity as well as a small separate left temporal convexity subdural hematoma. The interpreting radiologist discussed the findings with the neurologist. The same radiologist also interpreted the MRA, noting the exam was limited by motion. He reported no observation of gross intracranial aneurysm, and no identification of gross stenosis of intracranial circulation. A neurosurgeon evaluated the patient and his assessment was a small subdural hematoma, with no indication for surgery. He ordered a PT and INR, and started the patient on Keppra®.
The neurologist communicated to the patient and family that the MRI results showed evidence of a subdural hematoma and subarachnoid extension. He further explained that although the subdural hematoma was present on the initial CT, the management was unlikely to have been any different even if identified on the initial CT. The neurologist also suggested that the patient’s altered mental status might be secondary to seizure from the subdural hematoma. The patient remained at baseline with a normal mental status and a normal neurological exam. He was transferred to another facility for further management of his hemophilia, and later discharged in stable condition.
The patient sued the defendant radiologist who read the initial CT scan. He alleged a failure to identify a subdural hematoma that led to a delay in treatment causing him to suffer permanent cognitive deficits.
The plaintiff’s experts stated that the failure to recognize high-density extra-axial fluid collections on the CT as subdural hematomas violated the standard of care. They testified that the delay in treatment for the patient’s hemophilia led to permanent and disabling symptoms.
Experts for the defense testified the hemorrhage remained small and unchanged over the course of the studies, and at no point did the bleed cause significant mass effect, midline shift, or brain herniation. Hematology and neurology defense experts stated the plaintiff’s current condition had no causal relationship to any alleged brief delay in diagnosis, and they found no evidence of cognitive issues.
Resolution:
The plaintiff agreed to dismiss the case with prejudice during jury selection. Documentation of the comparative diagnostics and communication between specialists were critical elements leading to the dismissal of the case.
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