Commentary:
The jury agreed with the defendant neurosurgeon’s professional judgment to proceed with aneurysm clipping as opposed to transferring the patient to a specialty facility.
The Case:
An ambulance brought the patient, a 31-YOWF (5’4”, 200 lbs.), to the local emergency department with a sudden onset of severe head and neck pain, SOB, dizziness, and nausea. The patient indicated she was approximately three weeks pregnant; she had a history of cholecystectomy and gestational diabetes with her first pregnancy.
The ER physician consulted a neurosurgeon, who ordered a brain CT that revealed a subarachnoid hemorrhage (SAH). Initially, a CTA four hours after presentation was inconclusive for aneurysm; however, a repeat CTA approximately one hour later revealed a 9-mm aneurysm arising medially from the supraclinoid left internal carotid artery (ICA). The patient was admitted to ICU neurologically intact for consideration of surgery in the morning.
The following day, the neurosurgeon’s partner spoke to the patient and her husband. He documented that he referenced the studies and indicated the diagnosis of aneurysmal SAH. He told them the aneurysm was clippable, but also could possibly be treated by interventional radiology. He stated that the interventional radiology procedure (coiling) was not available at the hospital. His recommendation was urgent craniotomy with clipping. The neurosurgeon’s partner documented that he discussed risks and benefits of surgery in detail with the patient and her husband. They wished to proceed to surgery rather than waiting to consider a coiling option.
During the surgery, the clip was placed, but two separate episodes of arterial bleeding occurred; a second clip was applied. The hemorrhages were successfully stopped, but due to the resultant cerebral swelling it was decided to wrap the aneurysm with a combination of gauze and wispy cotton.
The day after surgery, the patient was unable to move the right side of her face and could not speak. A four-vessel angiogram revealed an “approximate 12-mm oval aneurysm projecting medially off the immediate supraclinoid portion of the left ICA.” The angiogram also showed a surgical clip lying just superior to the aneurysm. An additional small, 3-mm aneurysm near the junction of the A2 segment of the anterior cerebral artery and the callosomarginal artery was noted. The patient was transferred to a specialty hospital for possible coiling.
The patient’s husband consented to a cerebral angiogram and neuroendovascular coiling embolization procedure. Post-coiling, she experienced a thromboembolism and likely a vessel dissection, leading to a large ischemic stroke. She also suffered from an intracranial abscess requiring decompressive craniectomy and shunt placement for hydrocephalus. An inferior vena cava filter was placed due to multiple DVTs in her legs and a left lower lobe pulmonary embolism.
The patient spontaneously aborted the fetus which was then at approximately five weeks gestation. A tracheostomy was performed for respiratory failure. She had a subsequent burr hole craniotomy and evacuation of a chronic subdural hematoma. She required in-patient rehab for eight months and out-patient rehab over three years from the initial presentation for right hemiparesis and significant cognitive deficits.
In the suit, the plaintiff alleged the defendant neurosurgeon failed to consult with a neuro-interventionalist to assess whether coiling was safer or more effective than aneurysm clipping. The plaintiff also alleged failure to transfer her to a facility where such services were available, an improperly performed clipping procedure, and failure to obtain informed consent, resulting in permanent brain injury that caused both physical and cognitive deficits.
The defendant’s expert witnesses testified the aneurysm could be clipped or coiled, but due to the plaintiff’s young age and first trimester pregnancy, clipping was the preferred intervention. Coiling would have exposed the fetus to scatter radiation because the plaintiff’s morbid obesity would require extensive use of x-ray to clearly image the vessels. The expert stated that the risk of rupture during clipping versus coiling is the same because anytime an aneurysm is touched, a chance of bleeding occurs. The coiling procedure itself caused the vessel dissection, distal embolization, and left CVA—known complications of coiling.
Multiple plaintiff’s experts generally stated that a patient with an aneurysm at a low-volume facility with limited resources should be stabilized and transferred to a neurosurgery specialty facility for evaluation and treatment. Despite those testimonies, the jury agreed with the defendant’s judgment and found in his favor.
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