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Subdural Hematoma Following Vascular Surgery; Physician’s Motion Denied


A 67-year-old woman underwent a carotid endarterectomy (CEA), a procedure to remove build up from the carotid artery walls. The morning of the surgery the woman received a cervical block and the procedure began at 7:44 a.m. At 8:00 a.m., the woman’s blood pressure was recorded at 200/98, and the vascular surgeon clamped her carotid artery at 8:08 a.m. At 9:05 a.m., the woman received blood pressure medication, which lowered her blood pressure to 180/112, but it rose again to 190/80 by 9:45 a.m. During the CEA, the vascular surgeon determined that the woman’s artery blockage was more extensive than expected, and requested that the woman be fully anesthetized for the remainder of the surgery. The operation ended at 10:50 a.m., at which time the woman’s blood pressure was 175/60.

 

The woman was taken to the recovery room at 10:55 a.m., where her blood pressure was recorded at 192/96. At 12:15 p.m., the vascular surgeon assessed the woman’s condition and noted certain neurological symptoms that were consistent with a stroke. By 12:45 p.m., the woman was responsive to name, but was unable to follow commands. Shortly thereafter, the vascular surgeon ordered emergency exploratory surgery to determine the cause of the symptoms.

 

During the emergency surgery, the vascular surgeon did not discover any lesions, clotting, or embolism, but inserted a stent out of caution. The procedure ended at 3:45 p.m. and the woman was returned to the recovery room. When the vascular surgeon did not see improvement, he ordered a brain CT scan at 4:57 p.m. The woman was taken in for the scan at 6:30 p.m., and it was performed at 6:42 p.m. A radiologist interpreted the woman’s CT scan and stated that it revealed the presence of a chronic subdural hematoma with acute hemorrhage and subarachnoid bleeding. As the subdural hematoma expanded, it compressed the woman’s brain and caused death by shifting the brain to such an extent that it herniated the brainstem. At 7:45 p.m., the woman was placed on mechanical ventilation and taken to the intensive care unit. Life support was withdrawn the next morning and the woman died.

 

The woman’s estate filed a medical malpractice case against the hospital, the vascular surgeon, the vascular surgeon’s practice group, the anesthesiologist, and the anesthesiologist’s practice group.

 

The estate’s expert witnesses were deposed. One testified that the vascular surgeon and anesthesiologist breached the standard of care by failing to use a shunt during the period the woman was unconscious during the CEA, order a brain CT scan immediately after the second surgery when the vascular surgeon could not determine the cause of the woman’s neurological symptoms, and control the woman’s blood pressure after unclamping her carotid artery. The expert described the woman’s cause of death as compression of the brain and herniation of the brain stem resulting from a subdural hematoma and swelling of the left hemisphere. The expert opined that the bleeding began because the woman’s brain became less turgid during the CEA, causing it to pull away from the skull and tear blood vessels across the dural space. The expert described the woman’s condition as a low density subdural hematoma with a superimposed high density subdural hematoma and a subarachnoid hemorrhage.

 

The hospital, the vascular surgeon, the vascular surgeon’s practice group, the anesthesiologist, and the anesthesiologist’s practice group filed a motion to exclude the estate’s experts’ testimony and for summary disposition. The Macomb Circuit Court granted the motion, reasoning that the estate’s theories concerning the excess blood accumulated around the woman’s brain all relied on the premise that her brain retracted and severed blood vessels during the CEA, a theory which the Michigan Supreme Court rejected on a prior appeal. The trial court also rejected estate’s theory that failure to perform a timely CT scan after the second surgery caused the woman’s death. The trial court cited medical literature indicating that once cerebral hemorrhaging occurs, it is almost always fatal, and noted that Michigan law bars recovery in a medical malpractice action for an opportunity to survive unless that opportunity was greater than fifty percent.

 

The Court of Appeals of Michigan affirmed in part and reversed in part. The court held that the trial court did not err in concluding that the Michigan Supreme Court’s order covered more than merely testimony pertaining to the woman’s “chronic” subdural hematoma; the trial court did not err in concluding that hypertension was not a separate causal theory, but was instead a component of the same causal theory rejected by the Supreme Court; and the trial court erred in granting the defendants’ motion for summary disposition with respect to the estate’s CT scan causal theory based on the trial courts reliance on medical literature discussing a condition, intracerebral hemorrhaging, that the woman did not have.

 

The trial court did not err in concluding that the Michigan Supreme Court’s order covered more than merely testimony pertaining to the woman’s “chronic” subdural hematoma. The Supreme Court’s order did not only prevent the estate’s experts from testifying that the CEA caused a “chronic” subdural hematoma. Considering the context, the phrase “chronic subdural hematoma” was likely the best description of the woman’s complication. Based on their testimony, neither of the estate’s expert witnesses disagreed with describing the woman’s subdural hematoma as chronic. The Supreme Court’s order must be interpreted according to the decision it was reversing. The Supreme Court rejected the estate’s theory that the woman’s subdural brain bleed (whether acute or chronic) occurred as a result of lack of blood flow to her brain during the CEA, causing the brain to retract from the skull, tearing blood vessels, and creating a pathway for blood to accumulate in the subdural space.

 

The trial court did not err in concluding that hypertension was not a separate causal theory, but was instead a component of the same causal theory rejected by the Supreme Court. According to the estate’s experts, the woman’s subarachnoid hemorrhaging was merely a secondary effect of the torn bridging veins resulting from her alleged brain retraction.

 

The trial court erred in granting the defendants’ motion for summary disposition with respect to the estate’s CT scan causal theory based on the trial courts reliance on medical literature discussing a condition, intracerebral hemorrhaging, that the woman did not have. Both of the estate’s experts testified that the woman would have survived if she had received a CT scan immediately after her second surgery. The Supreme Court order did not address the estate’s experts’ testimony regarding the CT scan causal theory, and the trial court did not dismiss this theory on the basis that the expert testimony addressing it was inadmissible. The trial court granted summary disposition on this causal theory because it concluded that the woman did not have a greater than 50% chance at survival even if she had received a CT scan immediately after the second surgery. This determination was improper at the summary disposition stage given the previously cited expert testimony that the woman did have a greater than 50% chance of survival if she had received a CT scan immediately after the second surgery. The woman suffered from subarachnoid hemorrhaging and a subdural hematoma outside of the brain, but there was no evidence of intracerebral hemorrhaging within the brain tissue itself.

 

The Court of Appeals of Michigan affirmed in part and reversed in part the trial court’s grant of the defendants’ motion to summary disposition.

 

See: Tondreau v. Henry Ford Macomb Hosp., 2015 WL 5884949 (Mich.App., Oct. 8, 2015) (not designated for publication).

 

See also Medical Law Perspectives, December 2013 Report: Thicker Than Water: Liability When Blood Clots Cause Injury or Death 

 

 

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