By Stacey Kusterbeck
Emergency providers are ordering neurovascular imaging more often, especially CT angiography, for ED patients with indications such as headache or dizziness.1 “Multiple studies have shown limited utility of routinely doing these studies, which result in diagnosis of many incidental aneurysms,” says Ajay Malhotra, MBBS, MD, MMM, professor of radiology and biomedical imaging at Yale.
Management of intracranial aneurysms in EDs is inconsistent. “As we are scanning more patients, especially through the emergency department, we find more aneurysms,” Malhotra observes.
Medical/legal concerns often arise in the discussion for management of intracranial aneurysms. “But it wasn’t clear what aspect of aneurysm management was more likely to be a reason for liability,” Malhotra explains.
Malhotra and colleagues analyzed 133 malpractice case summaries from 2000-2020 involving negligence in diagnosis and management of a patient with an intracranial aneurysm.2 Researchers looked only at cases with jury awards and settlements. Not many cases involved incorrect interpretation of imaging studies. Failure to consider the possibility of an aneurysm, resulting in an inadequate workup, was a more common allegation.
“Although our study shows failure to image patients as a relatively frequent cause of litigation, it should be seen in context,” Malhotra cautions.
The findings do not imply EDs should be performing more imaging, according to Malhotra. “Following appropriate guidelines and ensuring appropriate follow-up may be more appropriate at avoiding malpractice litigation,” he adds.
There are various fact patterns that can involve intracranial aneurysms in ED cases. “However, unusual scenarios usually present the greatest risk,” says Moses Suarez, JD, a partner and co-chair of the healthcare industry group at Amundsen Davis in Chicago.
Thorough patient history and physical is crucial to timely diagnosis. Patient reports of headache, sensitivity to light, and temporary vision changes can be associated with migraine, particularly when the patient reports a history of migraines. “However, these symptoms can be associated with other vascular conditions,” Suarez warns.
Suarez represented an emergency physician (EP) in a case involving a woman who suddenly experienced headache, elevated blood pressure, and some brief vision changes. The symptoms were improving in the ED. Upon examination, the EP elicited some tenderness in the posterior neck and suspected a vertebral artery dissection.
While waiting to obtain a CT, the patient collapsed and coded with severe decerebrate posturing. CT imaging confirmed what the physician suspected: a right vertebral artery dissection. It also identified a secondary pathology: an intracranial aneurysm that had ruptured. Unfortunately, the patient did not survive a massive brain hemorrhage. During subsequent litigation, in addition to allegations of delayed diagnosis, the plaintiff attorney alleged the physician failed to lower the patient’s blood pressure, which caused the aneurysm to rupture. A jury found the hospital not liable. “Managing a patient’s blood pressure can be tricky given the potential risks of causing an ischemic stroke, particularly in a patient that has a history of elevated blood pressure,” Suarez notes.
Common allegations against emergency providers include missed or delayed diagnosis and failure to refer or consult with a specialist. “Documenting a thorough history and physical with a differential diagnosis is critical,” Suarez says.
As a best practice, Suarez says ED clinicians should document the top two or three potential diagnoses and the plan. “Follow up on the results of any ordered labs or radiology imaging, and adjust the diagnosis or plan accordingly,” Suarez advises.
Because of the potential for symptom overlap among various possible diagnoses in a fast-paced ED, documenting a differential diagnosis can be significant in cases involving missed or delayed diagnosis. “Without a through H&P and documented differential diagnosis, it can be difficult for the provider to recall what they were suspecting and the reasons for it,” Suarez explains.
REFERENCES
1. ElHabr A, Merdan S, Ayer T, et al. Increasing utilization of emergency department neuroimaging from 2007 through 2017. AJR Am J Roentgenol 2022;218:165-173.
2. Khan A, Khunte M, Wu X, et al. Malpractice litigation related to diagnosis and treatment of intracranial aneurysms. AJNR Am J Neuroradiol 2023;44:460-466.
Failure to image patients is a relatively frequent cause of litigation, but it should be seen in context. It is not so much incorrect interpretations of imaging studies; rather, failure to consider the possibility of an aneurysm, resulting in an inadequate workup, is a more common allegation.
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