Medical Malpractice Bulletin – January, 2017

In this issue:

Thunderclap headache: What’s the worst it could be – or not.

“Thunderclap headache” is defined as a severe headache that reaches its maximum intensity within 1 minute. The classic concern is a subarachnoid hemorrhage (SAH) resulting from a ruptured intra-cerebral aneurysm. According to an article by Schwedt et al., all patients with thunderclap HA should have a stat head CT with no contrast, followed by either an LP, CTA or MRI/MRA. But excluding SAH in such a patient is not the end. What else could it be? Here’s the list of most common mimics, according to Schwedt and colleagues:

  • Reversible cerebral vasoconstriction syndrome (RCVS): suggested by recurrent thunderclap headaches (2-10) over 1 to 2 weeks. Normal CT and LP, with vasoconstriction on angiography. Can lead to SAH, ICH or ischemic stroke.
  • Cervical artery dissection
  • Cerebral venous sinus thrombosis
  • Spontaneous intracranial hypotension: characterized by orthostatic HAs and auditory muffling.
  • Intracerebral hemorrhage
  • Exertional headache
  • “Primary”: a diagnosis of exclusion

And neck pain: What are the major non-musculoskeletal causes?

This bulletin has written extensively about spinal epidural abscess as a commonly missed diagnosis in patients presenting with neck pain. But again, what else could it be? What are non-traumatic, non-musculoskeletal causes of neck pain? Here’s a list presented by Dr. Michael Bond in UMEM Educational Pearls:

  • Early mengingitis (84% of patients with meningitis will complain of neck stiffness)
  • Myocardial infarction/angina. Women are known to have atypical symptoms and might just have dull pain in their neck. Be sure to ask about whether exertion increases the pain.
  • Epidural Abscess- fever and neuro symptoms are often missing early on. Make sure to ask about risk factors for spinal epidural abscess.
  • Vertebral Artery Dissection – most common identifiable cause of stroke in your people (<50% are associated with trauma and <8% of patients have connective tissue disorder.) Patients are at increased risk if they have had:
    • Cervical trauma
    • Recent infection
    • Hypertension
    • h/o migraines

Endovascular therapy for stroke: The new frontier

You may have heard about endovascular “clot retrieval” being the latest thing for treatment of stroke since the invention of the knife to slice bread. It’s good, yes, but not appropriate for every stroke patient. These interventions, similar to stenting a coronary artery for a heart attack, are proving effective in treating certain strokes more effectively and at a later point after onset than tPA/thrombolysis. The key word is “certain;” clot retrieval is not the best approach for every stroke. Here’s a compendium of recently published articles on the pros and cons of clot retrieval or endovascular approaches to the treatment of stroke. If you read this list, or even keep it for reference, you must have been involved a a lot of stroke litigation.

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