Undiagnosed Left Posterior Artery Aneurysm Resulted in Subdural Hematoma and Death

Allegation

The emergency department physician failed to timely diagnose a left posterior artery aneurysm resulting in a subdural hematoma and death.

Case Details

A 42 YOF presented to the emergency department complaining of a headache for two weeks. She also complained of dizziness, and low back pain radiating down her spine to her tailbone. She was seen by an emergency medicine physician (ED physician #1) who ordered a head CT without contrast, which was unremarkable. She also found no signs of meningitis. She noted that she didn’t think an MRI or other imaging was appropriate at that time. The patient was provided hydrocodone w/acetaminophen and discharged.

A week after the emergency department visit, the patient was seen by a neurologist, accompanied by her father. The patient reported that she had severe headaches occurring over the previous three weeks. She particularly noticed them after intercourse with her boyfriend. She stated that one time after intercourse, the headache pain was so severe that she couldn’t move and slept for two hours. She also stated that she experienced dizziness and numbness.

After the neurologist examined the patient, he told the patient and her father that she could be suffering from a low-pressure headache, but an intra-cranial aneurysm must be considered. He noted that her symptoms were quite concerning. The neurologist told the patient to go to the emergency department. The patient was very upset when told how serious her condition might be and began to cry. The neurologist told her that to ensure she received a complete evaluation, he would call the emergency department and send a follow-up fax. The fax note stated: “I have suggested the patient go to the emergency room for evaluation and have called the ED to assure she gets a complete evaluation. She may be suffering from a low-pressure headache however an intra-cranial aneurysm must be considered. Suggest an endovascular evaluation and possible cerebral angiogram. Return to the office in one week. Patient’s father was present at the time of this suggestion.” The patient did not go to the emergency department or make a one-week follow-up appointment with the neurologist as directed.

The next day the patient presented to a primary care practice and was seen by a family practice physician (FP). The patient complained of a headache, neck pain, and low back pain radiating down her leg. The FP referred the patient to Neurology, noting on the referral that the patient did not go to the ED as recommended by her previous neurologist because she was afraid of the recommended follow-up testing. The FP also told the patient to go to the ED if her symptoms worsened.

The patient presented to the emergency department the evening of the following day, accompanied by her father. The triage nurse noted “patient sent here by neurologist for possible aneurysm”. The patient’s vitals were normal, but she was noted to be anxious and crying. The patient may have given the nurse a copy of the ED referral from the neurologist and the family medicine physician’s note as both were later found in the hospital record.

The patient was seen by an emergency medicine physician (ED physician #2). The physician noted a presentation of headache, back pain, and neck pain. He also noted that the CT from the previous ED visit was normal. ED physician #2 denied that the patient or her father ever told him that she had been referred by a neurologist to rule out possible aneurysm. ED physician #2 also denied ever seeing a neurology referral or any note pertaining to a possible aneurysm. He admitted that he did not look at the nurse triage note. He ordered an MRI of the cervical spine and entered an order for ondansetron. The MRI revealed bulging discs. ED physician #2 noted “the patient will follow up with Dr. Smith who she has seen in the past for this.” The patient was then discharged.

Four weeks later the patient was found unresponsive in her garage. She was taken by ambulance to the emergency department where she was intubated. A head CT showed an acute intra-cranial hemorrhage with mass effect and midline shift. She was taken to surgery where a neurosurgeon performed a left decompressive hemicraniectomy, evacuation of subdural hematoma and intra-parenchymal hematoma, and clipping of a complex left posterior communicating artery aneurysm. The post-operative diagnosis was a ruptured posterior communicating artery aneurysm, subdural hematoma, subarachnoid hemorrhage, and intra-cerebral hemorrhage. The patient was transferred to ICU in critical condition. She was absent brainstem reflexes. The family decided to withdraw care the next day and the patient expired.

Expert Testimony

The defense emergency medicine expert could not support the care of ED physician #2. He was surprised that the patient or her father did not mention the possibility of aneurysm to ED physician #2 but said the physician should have read the nurse’s triage note which clearly mentioned it. Also, if ED physician #2 ordered a cervical spine CT to investigate the complaints of neck pain, he should have also ordered a head CT due to the complaints of headache.

A neurosurgeon defense expert also could not support ED physician #2’s care. He said that although the patient and her father are not blameless, this is a classic case of missed sub-arachnoid hemorrhage. Even without the fax from the neurologist in the chart, the nursing triage note indicated the need for work-up for possible aneurysm.

Both the emergency physician and neurosurgery expert supported the care of ED physician #1. A complaint of headache for two weeks was an atypical presentation for an aneurysm or meningitis. A non-contrast CT was an appropriate test to administer at that point.

Resolution

Due to lack of expert support for the care provided by the ED physician #2 and the tragic outcome, the case was settled.

Risk Reduction Strategies

Thoroughly review pertinent notes in the medical record that may be relevant to patient care, including nursing triage notes.

Foster communication with nurses and other healthcare providers in the emergency department so physicians are informed of important information.

Bring any issues with the electronic health record to the attention of department and hospital administration, e.g., triage notes not easily accessible.

Ensure that documentation supports the complexity of the patient evaluation and/or the treatment, including thought processes and medical decision-making.

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