Malpractice Litigation Related to Diagnosis and Treatment of Intracranial Aneurysms.

BACKGROUND AND PURPOSE: Approaches to management of intracranial aneurysms are inconsistent, in part due to apprehension relating to potential malpractice claims. The purpose of this article was to review the causes of action underlying medical malpractice lawsuits related to the diagnosis and management of intracranial aneurysms and to identify the factors associated and their outcomes. MATERIALS AND METHODS: We consulted 2 large legal databases in the United States to search for cases in which there were jury awards and settlements related to the diagnosis and management of patients with intracranial aneurysms in the United States. Files were screened to include only those cases in which the cause of action involved negligence in the diagnosis and management of a patient with an intracranial aneurysm. RESULTS: Between 2000 and 2020, two hundred eighty-seven published case summaries were identified, of which 133 were eligible for inclusion in the analysis. Radiologists constituted 16% of 159 physicians sued in these lawsuits. Failure to diagnose was the most common medical malpractice claim referenced (100/133 cases), with the most common subgroups being "failure to include cerebral aneurysm as a differential and thus perform adequate work-up" (30 cases), and "failure to correctly interpret aneurysm evidence on CT or MR imaging" (16 cases). Only 6 of these 16 cases were adjudicated at trial, with 2 decided in favor of the plaintiff (awarded $4,000,000 and $43,000,000, respectively). CONCLUSIONS: Incorrect interpretation of imaging is relatively infrequent as a cause of malpractice litigation compared with failure to diagnose aneurysms in the clinical setting by neurosurgeons, emergency physicians, and primary care providers.

Contextualizing the use of oncologic imaging within treatment phases: imaging trends and modality preferences, 2000-2014.

BACKGROUND: In the present study, we retrospectively evaluated the use of tomographic imaging in adult cancer patients to clarify how recent growth plateaus in the use of tomographic imaging in the United States might have affected oncologic imaging during the same period. METHODS: At a U.S. academic cancer centre, 12,059 patients with dates of death from January 2000 through December 2014 were identified. Imaging was restricted to brain and body computed tomography (ct), brain and body magnetic resonance (mr), and body positron-emission tomography (pet) with and without superimposed ct. Trends during the staging (1 year after diagnosis), monitoring (18-6 months before death), and end-of-life (final 6 months before death) phases were analyzed. RESULTS: Comparing the 2005-2009 with the 2010-2014 period, mean intensity of pet imaging increased 21% during staging (p = 0.0000) and 27% during end of life (p = 0.0019). In the monitoring phase, mean intensity for ct brain, ct body, and mr body imaging decreased by 26% (p = 0.0133), 11% (p = 0.0118), and 26% (p = 0.0008), respectively. Aggregate mean intensity of imaging increased in the 13%-27% range every 3 months from 18 months before death to death, reaching 1.43 images in the final 3 months of life. Patients diagnosed in the final 18 months of life had an average of 1 additional image during both the 3 months after diagnosis (p = 0.0000) and the final 3 months before death (p = 0.0000). CONCLUSIONS: Imaging increased as temporal proximity to death decreased, and patients diagnosed near death received more staging imaging, suggesting that imaging guidelines should consider imaging intensity within the context of treatment phase. Despite the development, by multiple organizations, of appropriateness criteria to reduce imaging utilization, aggregate per-patient imaging showed insignificant changes. Simultaneous fluctuations in the intensity of imaging by modality suggest recent changes in the modalities preferred by providers.

Limited ischemic necrosis despite prolonged basilar artery occlusion treated with local thrombolysis: a clinicopathologic study.

Based on published case series, intra-arterial thrombolysis for basilar artery occlusion reduces mortality and improves outcome even when performed after considerable delays. In contrast, the current use of intravenous thrombolysis is limited to a 3-hour time window. The longer time window for intervention in patients with basilar artery occlusion may vary based on individual clinical features, such as collateral circulation and the site of the occlusion. Clinicopathologic evidence is presented from a patient with a distal basilar artery occlusion treated with local thrombolysis who later expired from a myocardial infarction complicated by cardiac tamponade. Autopsy showed infarction limited to the right pons despite symptom duration of over 72 hours and directly observed neurologic deficits for 27 hours.

Cost utility analysis of radiographic screening for an orbital foreign body before MR imaging.

BACKGROUND AND PURPOSE: Our purpose was to evaluate the cost-effectiveness of clinical versus radiographic screening for an orbital foreign body before MR imaging. METHODS: Costs of screening were determined on the basis of published reports, disability rating guides, and a practice survey. Base case estimates were derived from published guidelines. A single-state change model was constructed using social cost as the unit of analysis. Sensitivity analysis was performed for each variable. The benefit of screening was avoidance of immediate, permanent, nonameliorable, unilateral blindness. RESULTS: Using base case estimates and a discount rate of zero, we calculated the cost of the current guideline as $328,580 per quality-adjusted life-year saved. Sensitivity analysis identified screening cost as a critical variable. Discount rates and effectiveness of foreign body removal also were found to be important factors. Probability of injury and prevalence of foreign body may impact the analysis. CONCLUSION: Clinical screening before radiography increases the cost-effectiveness of foreign body screening by an order of magnitude, assuming base case ocular foreign body removal rates. Asking the patient "Did a doctor get it all out?" serves this purpose. Occupational history by itself is not sufficient to mandate radiographic orbital screening. Current practice guidelines for foreign body screening should be altered.

Evaluation of meniscal tears: fast spin-echo versus conventional spin-echo magnetic resonance imaging.

RATIONALE AND OBJECTIVES: We compared the performance of fast spin-echo (FSE) with conventional spin-echo (CSE) magnetic resonance (MR) imaging sequences in the detection of meniscal tears. METHODS: Seventy-three patients underwent MR examination of the knee for suspected internal derangement. Each patient was scanned with a CSE sequence and one of two FSE sequences. The primary difference between the two FSE sequences consisted of the echo train length (ETL). Thirty-seven patients (group 1) were scanned with the FSE I sequence (ETL = 8), and 36 patients (group 2) were scanned with the FSE II sequence (ETL = 4). Menisci were graded as torn or not torn on the basis of their MR appearance. The sequences were compared with each other and with the surgical findings in 31 patients who underwent arthroscopy. RESULTS: In group 1, there was a significant discrepancy between the CSE and FSE I techniques (p = .006). The FSE I sequence detected only 11 of 19 surgically proven torn menisci as opposed to 18 of 19 detected with the CSE sequence. The FSE II sequence performed significantly better in group 2, with an accuracy equal to that of the CSE sequence. CONCLUSION: FSE sequences are extremely technique dependent with regard to detecting meniscal tears and should not replace CSE sequences in this setting until further studies are performed to optimize the technique.

Magnetic resonance imaging of brain herniation into the middle ear.

Four patients with cholesteatoma were shown to have a large area of eroded tegmen tympani on computed tomography (CT). Magnetic resonance imaging (MRI) in the coronal and sagittal plane showed temporal lobe herniation in three cases and cholesteatoma with abscess elevating the dura in one case. In the patient with a cholesteatoma and an eroded tegmen tympani on CT, MRI is indicated to rule out brain herniation into the middle ear.

Metastases to the adrenal glands and the development of Addison's disease.

Metastases to the adrenal glands are common in patients with cancer but symptomatic Addison's disease is rarely noted in this population. The development of body computerized tomography (CT) allows the diagnosis of adrenal metastases to be made more readily antemortem. From 1980 to 1981, 19% (4/21) of patients at the Massachusetts General Hospital who had metastatic cancer and who were noted to have enlarged adrenal glands on CT also had or developed symptomatic adrenal insufficiency. The case histories of 8 patients with Addison's disease and one patient with adrenal hemorrhage on the basis of metastatic infiltration are reviewed. Since adrenal insufficiency may develop abruptly in this group of patients, it is suggested that prophylactic maintenance glucocorticoid therapy be initiated as soon as the diagnosis of adrenal metastases is made.