This case involves an otherwise healthy patient that presented to his primary care physician with extreme shortness of breath in Utah. He was admitted and was discharged almost immediately with a prescription for Xarelto. Several days later, the patient suffered a stroke while at work. He presented to the emergency room within an hour of the onset of his symptoms. However, he was not given tPA or an IVC Catheter due to the fact that he was on blood thinners. The patient was then transferred to a larger hospital for surgical intervention; however, by the time he arrive the clot had grown too large to operate on. The patient died several days later while in the hospital.
Question(s) For Expert Witness
- 1. Could the delay for care by the neurosurgeon have caused the clot to increase in size and thus render it inoperable?
- 2. What is the required response time for attending to a patient that has a cerebral blood clot for intervention?
Expert Witness Response E-101595
It is possible for the delay for care by the neurosurgeon to have caused the clot to increase in size and thus render it inoperable. The images would determine if that may have caused it. If a patient has a cerebral blood clot, the required response time for intervention is critical. Time is brain; thus, the sooner the better. Currently, the AHA recommends a door-to-puncture of the groin of less than 90 min after hospital arrival. If everything goes right, the recanalization of the vessel should be completed within 120 min of arrival. I participate on Quality Improvement Committees at different institutions. As such, I review cases like this on a frequent basis, and have lectured on this topic before.
Expert Witness Response E-000572
The clot may have been getting larger due to the blood thinners and a tendency for clots in the brain to grow over the first 12 hours. How much the clot grew by the time the patient arrived at the other hospital can be determined by evaluating the scans. This might be able to determine how much impact the 2 hour delay in being evaluated by the neurosurgeon may have had on his eventual outcome. I have reviewed similar cases and have had experience evaluating and treating patients with intracerebral hematomas and blood thinning medication, and I have also lectured about this condition.