ER Expert Witness Comments on Delayed Diagnosis of Infarction

This case involves a forty-three-year-old obese male with a one-month history of one-sided neck pain, headache, and elevated blood pressure.  He presented to his family physician due to elevated blood pressure, discomfort in his neck when lying on his left side, headache, and elevated blood pressure.  The patient followed up with his physician four times with the same symptoms and no improvement, despite treatment.  One day later, the patient experienced dizziness, left sided paresthesias, and neck pain. EMS was called and paramedics transported him to the Emergency Department. An MRI was ordered; results showed left vertebral artery dissection and secondary acute to early subacute infarction of left dorsolateral spinal cord at the level of C1. Subsequently, the patient suffered from a severe physical disability and chronic pain.

Question(s) For Expert Witness

Expert Witness Response E-000320

Arterial dissections are a common cause of stroke in the young age population. While clinical features may raise suspicion for dissection, the diagnosis is confirmed by neuroimaging findings, particularly the demonstration of a long tapered arterial stenosis, a tapered occlusion, a dissecting aneurysm (pseudoaneurysm), an intimal flap, a double lumen, or an intramural hematoma. A headache or neck pain at onset may suggest underlying dissection, especially as a cause of stroke in the young. I suggest lumbar puncture and cerebrospinal fluid analysis to exclude subarachnoid hemorrhage for patients with suspected dissection who have severe or sudden onset headache, and for patients who have intracranial dissection or intracranial extension of extracranial dissection, particularly if treatment with anticoagulation is being considered. A non-remitting headache should strongly suggest the need for further work-up, especially in a young patient.

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