Aneurysm, subarachnoid hemorrhage, vasospasm and stroke – a closer look.
We have seen several cases in the Courts across Canada dealing with medical malpractice claims analyzing the issue of standard of care and causation relating to aneurysms and resulting stroke.
Today we will share a few facts about this type of brain bleed. Typically symptoms may include a history of headaches, fever, nausea, vomiting, blurry vision, and neck stiffness to name a few. At times, these symptoms may be confused with migraine headaches. An angiogram is a test that would be conducted to identify a ruptured aneurysm. For a diagnosis of subarachnoid hemorrhage, a lumbar puncture may also be undertaken to assist in such a diagnosis. Recommendations for a clear diagnosis on aneurysms, including assessments of headaches that may be linked to a ruptured aneurysm, would be a neurologist and/or a neuro-surgeon.
“The most frequent cause of SAH is head trauma in seventy percent (70%) of cases. A traumatic SAH is a self-limiting condition for which there is generally no treatment other than medication prescribed. However, in almost thirty percent (30%) of cases, blood found in the subarachnoid space is caused by spontaneous and life-threatening conditions, the most frequent of which is due to leaking or ruptured aneurysm. A small percentage of cases of spontaneous SAH may also be due to arteriovenous malformation, another life-threatening condition.” This quote is referenced in Williams v. Bowler, 2005 CanLII 27526 (ON SC).
In another decision of the Court, we review a case regarding an unfortunate situation in 2006 dealing with ruptured aneurysm and symptoms that follow. This case is referenced as Borglund v. Fraser Valley Health Region et al, 2006 BCSC 1338 (CanLII).
The Plaintiff was involved in a road rage altercation wherein another driver punched the Plaintiff in the head. A few days later an existing aneurysm ruptured, resulting in a subarachnoid hemorrhage.
The initial diagnosis in this case was concussion as opposed to aneurysm. As a result of the concussion diagnosis, a CT scan was not ordered on the 1st or 2nd visit to the hospital, resulting in a delay in diagnosis of aneurysm and necessary treatment.
Here is the timeline:
Dec 17, 1999 – road rage incident
Dec 19, 1999 – attended emergency
Dec 20, 1999 – attended emergency again
Dec 21, 1999 – attended emergency again, referred to neurologist, CT scan ordered
Dec 22, 1999 – diagnosis was made
An important fact outlined in this case was that the rupture of the existing aneurysm was not caused by the road rage incident. “The parties agree that the ruptured aneurysm was not caused by the earlier punch to the head, suffered in the road rage incident.”
This claim names the Fraser Valley Health Region and various doctors as Defendants. The legal theory in this case as presented by the Plaintiff is that the named Defendants allegedly failed to meet the standard of care in failing to diagnose the subarachnoid hemorrhage and initiate treatment. An urgent CT scan was not ordered on the 1st or 2nd visit to hospital, nor was the Plaintiff referral to a neurologist until the 3rd visit to hospital. It is the Plaintiff’s position that this delay resulted and caused the severe and prolonged vasospasm. In other words, had the diagnosis of aneurysm been made earlier, it is argued that earlier treatment may have prevented the resulting vasospasm.
The Court did not agree with the Plaintiff. The claim was not successful. The action was dismissed with costs to the Defendants. There is a lot to learn, however, from reviewing this case.
What is a subarachnoid haemorrhage?
A subarachnoid haemorrhage means that there is bleeding in the space that surrounds the brain. Most often, it occurs when a weak area in a blood vessel (aneurysm) on the surface of the brain bursts and leaks. The blood then builds up around the brain and inside the skull increasing pressure on the brain.
What is vasospasm?
Humans rely on blood vessels called arteries to carry oxygen-rich blood to all parts of our bodies. Vasospasm occurs when an artery suddenly narrows and the blood supply is drastically reduced. It most often happens in the brain or in the heart. The results can be serious. Sometimes the term vasospasm is used to describe the narrowing of small blood vessels in the hands.
What Is a Cerebral Vasospasm?
“Vaso” means vessel. A spasm is a sudden muscular contraction. A vasospasm is a sudden contraction of the muscular walls of a blood vessel. In some cases, we know what causes the muscles to contract. Other times it’s a mystery.
Cerebral relates to the brain. A cerebral vasospasm almost always follows another major event inside the skull, called a subarachnoid haemorrhage (SAH). This is a kind of stroke that happens when a blood vessel on the surface of the brain breaks. Blood fills the space between the skull and the brain. It leaks beneath the arachnoid membrane.
Subarachnoid hemorrhage or SAH is most often caused by an aneurysm. An aneurysm is a weak place in a blood vessel often resulting in a balloon-like bulge. SAH is the most dangerous type of stroke. You might survive the stroke but then have a cerebral vasospasm, which puts your health and life at risk for a second time. See link
The literature provides the following list of symptoms as it relates to vasospasm
Symptoms of a vasospasm can vary depending on the area of the body affected. When the condition occurs in the brain symptoms may include:
Difficulty with speaking
Weakness on one side of the body
Patients who have experienced a cerebral vasospasm often also have stroke-like symptoms:
Numbness or weakness of the face, arm or leg, especially on one side of the body
Trouble seeing in one or both eyes
Dizziness, loss of balance or coordination
Severe headache with no known cause
The Plaintiff in this case had the following symptoms as reported by the emergency room physician
- Intense headache described as “severe”
- Numbness and tingling on right side of head
- Nausea with vomiting
While the Plaintiff attended hospital a few times reporting severe headaches with nausea and vomiting, he was diagnosed with concussion and released from hospital. A third attendance to hospital resulted in further symptoms of dehydration and looking quite unwell, and the emergency room physician referred the Plaintiff to a neurologist for consultation.
Neurologist recorded the following further symptoms
- Head trauma
- No loss of consciousness after being struck to the head
- Discomfort in temporal frontal area
- Numbness in right arm and leg
- Constant headache since the incident of assault
- Not eating well
- Dehydrated with dry mouth and mucous membranes
As a result, the Plaintiff was hospitalized for observation and a CT scan was finally ordered. Intravenous fluids were also commenced. CT Scan showed subarachnoid blood and surgery was required by a neuro-surgeon as 3 aneurysms were found and 2 of the 3 aneurysms were clipped in surgery. Medication was also prescribed to reduce the risk of secondary ischemic injury or stroke following an aneurysm. His symptoms continued post surgery with right-sided drift, increased focal deficit to his right leg and further imaging showed vasospasm of the anterior cerebral complex. Although treated, his condition deteriorated.
The Plaintiff developed pulmonary edema, pneumonia and a seizure – he suffered “severe and prolonged vasospasm which left him with infarcts in the area of his left anterior cerebral artery. He was left with problems of receptive and expressive speech as well as other cognitive deficits.” He attended GF Strong for rehabilitation but remains with symptoms of decreased cognition, reasoning, right-sided weakness, speech deficits. He requires supervision in self-care. The Plaintiff also has problems with safety awareness, judgment and problems with balance and coordination.
- Did the physicians owe this Plaintiff a duty of care?
- Was there a breach of the duty of care?
- Did such breach cause or contribute to the injury that resulted?
While it is fairly straight forward to establish that a duty of care may be owed to a Plaintiff (patient), that is not always the case as it relates to proving that a breach of the said duty occurred or more importantly, the test of causation.
The legal theory of the Plaintiff in this case is that the delay in diagnosis and in treatment resulted in the outcome, and had treatment been initiated earlier, and prior to Dec. 22, 1999, the outcome would not have been as serious, leaving him with the resulting injury.
The legal theory of the Defendants is that a delay in treatment did not worsen the Plaintiff’s condition, and therefore, causation is not established, and this claim must be dismissed.
The conclusion in this case is noted:
In the result, I find that the defendants owed the plaintiff a duty of care to provide medical treatment consistent with that of reasonable emergency room physicians in the circumstances and that the defendants failed to meet that standard of care. I find, however, that the defendants’ failure to diagnose the plaintiff’s condition did not ultimately worsen the plaintiff’s outcome. The action is dismissed, with costs to the defendants.
I will identify some of the evidence directly from this decision that was put before the Courts, sharing the interesting points as it relates to aneurysms.
Standard of care (Plaintiff)
- The onus is on the emergency room physician to exclude the presence of significant underlying pathology.
- The most important cause of this pattern of headache is subarachnoid haemorrhage.
- A CT scan and, if necessary, a lumbar puncture are indicated.
- Subarachnoid haemorrhage is a neurological and neurosurgical emergency which must be considered by all physicians evaluating acute headaches, particularly in the emergency department setting.
- The persisting complaints of a severe headache in a patient who has no prior history of similar headaches and the fact that the headaches were accompanied by persisting nausea and vomiting to the point of dehydration should have alerted the assessing physicians to the possibility of a potentially catastrophic intracerebral condition.
- There is a positive family history for cerebral aneurysms.
- The failure to take steps easily available to rule out a serious underlying condition (with potentially catastrophic consequences) amounts to conduct below the standard of regular practice.
Standard of Care (Defence)
- The record also indicates a normal neurological examination.
- The record also indicates that the patient responded very well to relatively conservative treatment
- Very good follow-up instructions was given.
- The diagnosis of concussion is entirely reasonable given this presentation.
- CT would be strictly a judgment call.
- There is also a continued pressure on physicians to manage resources.
- Every patient that presents cannot obviously be investigated.
Following is a very interesting comment that most members of the public do not consider when they attend at emergency or even at their doctor’s office. A statement from the Court:
In my view, each of Drs. X and Y were distracted by the assault which Mr. x had experienced earlier in the day of December 17, 1999. They associated the headache with the assault, likely because Mr. x associated his headache with the assault.
The question then is – should a patient be explaining what happened ? The incident itself – if it is a potential to cause a “distraction” – or are physicians trained enough to not be “distracted” by associating the cause of the “symptoms” to the incident. Would a doctor opine differently if they did not have a reason for the headaches ?
The Court further agreed with the following medical opinion provided by experts retained by the Plaintiff:
“it is the emergency physician’s duty to obtain sufficient information in the history to distinguish potentially life threatening headaches from more benign headaches, that is, to distinguish those that require urgent treatment from those which may be treated conservatively.”
As it relates to breaching the standard of care, the Court stated the following:
“In failing to ask questions necessary to rule out a serious underlying cause when the plaintiff was capable of providing informative responses, Drs. X and Y failed to meet the standard of care of a reasonable emergency room physician in the circumstances.”
On the topic of causation, here are a few facts derived from the case from both sides
- the standard treatment for subarachnoid hemorrhage is to institute the drug Nimodipine immediately, to operate to repair the aneurysm, to rehydrate the patient to uvolemic levels and, if vasospasm develops, to raise the plaintiff’s blood pressure and blood volume.
- cerebral vasospasm occurs as a direct result of the subarachnoid hemorrhage
- It is a serious and often devastating condition, caused by the breakdown of blood components in the subarachnoid space and their effect on the cerebral blood vessels.
- The incidence and severity of spasm is related to the amount of blood at the time of the bleed.
- The amount of blood revealed on a CT scan of a patient’s brain can predict the likelihood that vasospasm will develop.
- When severe, it causes cerebral infarction, neurological deficit and death.
While both parties had different positions on whether delayed treatment caused the serious vasospasm, the Court found, as a finding of fact, that causation had not been established, and the case was dismissed with costs to the Defendants.
See Disclaimer in About Page