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Aqueductal stenosis, obstructive hydrocephalus, and the risks of delaying surgery

Fast action may be needed when there's a change in neuro status

Given the limited space in the head, anything that takes up too much room in your brain can cause life-threatening problems.

Hydrocephalus is one of those medical conditions, with a name that literally means “water on the head.” More accurately, hydrocephalus is caused by a buildup of cerebrospinal fluid (CSF) in the brain. Doctors diagnose this condition based on a diagnostic radiology workup with a CT scan and/or MRI scan.

After identifying hydrocephalus on radiology films, the next step for the doctors is to determine the cause and, most importantly, whether urgent surgical intervention is needed.

Aqueductal stenosis is one of the classic conditions that can cause hydrocephalus and requires urgent surgery. To understand what aqueductal stenosis is, it’s helpful to provide a little information about neuroanatomy. The brain produces CSF in structures called the lateral ventricle and third ventricle. The CSF normally flows out of those ventricles and through the aqueduct into another structure, the fourth ventricle of the brain.

When the aqueduct is constricted, narrowed, or obstructed, it’s called aqueductal stenosis. Because the CSF isn’t flowing properly, yet continues to be produced in the brain, there is a buildup that occupies precious space in the brain. It’s called obstructive hydrocephalus.

For many patients, the first sign of aqueductal stenosis is an altered mental status, which can come in the form of behavior that’s unusual for the person, disorientation, confusion, or even difficulty speaking. When a doctor hears from the patient or family members that these symptoms suddenly have appeared, the standard of care requires ordering radiology studies to investigate the cause.

Some patients who have aqueductal stenosis have actually had an anatomical defect from birth, without any recognizable symptoms for many years. That’s called congenital aqueductal stenosis. Other patients develop the condition as a child or adult, called acquired aqueductal stenosis.

Either way, there are two surgical options to address aqueductal stenosis and subsequent hydrocephalus. First is the surgical insertion of a shunt or drain. The second is called a third ventriculostomy, which involves surgically creating an opening in the floor of the third ventricle to allow drainage of CSF.

The timing of surgery

Neurosurgical experts agree that the standard of care requires urgent surgery, but the question of whether a patient’s particular condition requires emergency surgery is a more subtle one. The answer depends on whether the patient is neurologically intact.

We represented a medical malpractice plaintiff who had a case of sudden onset congenital aqueductal stenosis. According to the neurosurgeons who evaluated the patient, the exam showed that the patient was neurologically intact. This means that there were no motor or sensory abnormalities uncovered during the physical exam.

In that situation, our expert witnesses felt that their decision to delay third ventriculostomy surgery until the next morning was appropriate because the patient was neurologically intact.

Close neuro monitoring pending surgery

In the same case, the patient was admitted to the intensive care unit (ICU) for continuous hydrocephalus monitoring, with the idea that the nursing staff would notify the neurosurgery team if there were any changes in the patient’s neurologic status. Unfortunately, that didn’t occur, and the patient’s brain eventually herniated, causing a massive permanent brain injury.

Monitoring patients with obstructive hydrocephalus and aqueductal stenosis is critical when the neurosurgeon determines that the shunt or third ventriculostomy surgery doesn’t have to be performed on an emergency basis. When nurses drop the ball and don’t inform the neurosurgeon of changes in the patient’s status, it can have a deadly outcome.

As in so many areas of healthcare, when the patient is transferred from one provider to another, there’s another potential danger to the patient.

That’s what happened in a case decided by Houston’s First Court of Appeals, styled Tracy Windrum v. Victor Kareh, M.D., No. 17-0328 (Jan. 25, 2019). There, the patient had classic hydrocephalus symptoms, including disorientation and slurred speech.

The neurologist who saw the patient in the hospital diagnosed him with compensated obstructive hydrocephalus and told the patient’s wife that he would go to surgery the next day for insertion of a shunt. The neurologist referred him to a neurosurgeon, Dr. Victor Kareh.

Dr. Kareh saw the patient the next day. He didn’t review the patient’s medical history, and the patient didn’t exhibit any of the same neurological symptoms he’d had the previous day.

The neurosurgeon placed a ventricular drain to monitor the patient’s intracranial pressure for 24 hours. He decided that the patient didn’t immediately need a shunt but would probably need one in the future. He ended his treatment without performing a third ventriculostomy or shunt placement, which are the only two treatments recognized by the standard of care.

Unfortunately, based on lack of neurosurgical treatment and overall mismanaged follow-up care, the patient died in his sleep from this dangerous condition a few months later.

If you or someone you care for has been seriously injured because of poor neurology or neurosurgical care, then contact an experienced, top rated Houston, Texas medical malpractice lawyer for help in evaluating your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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