Delayed Diagnosis of Cerebral Hemorrhage Leads to Neurological Defects

Case Overview

This case involves a 36-year-old pregnant woman who had experienced debilitating headaches throughout her pregnancy. She was admitted to the hospital due to preeclampsia. Prior to the delivery, the patient continued to have excruciating headaches. The patient had a normal delivery, after which her headaches began to subside. After almost 48 hours in the hospital, the patient’s headaches appeared stable. No imagining was conducted and the patient was discharged. The following night, the patient developed slurred speech and intense headaches while at home. The patient’s husband brought her back to the emergency department and imaging revealed a cerebral hemorrhage and venous sinus thrombosis. The patient was initiated on anticoagulation and required a decompressive craniectomy, which caused the patient persistent neurological deficits.

Questions to the Neurology expert and their responses

How frequently do you treat patients with venous sinus thromboses?

Our neuroscience ICU, in which I am an attending physician, admits approximately 4-7 cases of cerebral venous thrombosis (CVT) every year. The diagnosis is in the differential for many more women we see with acute headache and neurological signs and symptoms.

If the thrombosis had been identified and treated earlier, how would the prognosis have changed?

Early diagnosis is, of course, paramount to management, since this is a syndrome which is particularly responsive to anticoagulation with heparin and early therapy may ameliorate neurological deficits. Heparinization, in the setting of CVT, can prevent thrombus propagation and potentially gives the patient a better chance of avoiding hemorrhage expansion, and cerebral edema, which, as may have happened in this case, leads to the need for decompressive craniectomy to prevent herniation.

About the expert

This expert has over 30 years of experience in the field of neurology and neurocritical care. She earned her BA in philosophy from Oberlin College and her MD from Case Western Reserve University School of Medicine. She then completed a residency in internal medicine and a second residency in neurology at the University of California, San Francisco, followed by a fellowship in neurocritical care at the University of Cincinnati. Today, this expert is board certified in both neurology and neurocritical care. She is an active member of several professional societies, including the American Academy of Neurology, the Neurocritical Care Society, and the Society for Critical Care Medicine. This expert previously was the director of the headache and pain clinic at the University of Kentucky, the medical director of the Kentucky Neuroscience Institute, and an associate professor of neurology at Case Western Reserve University and the University of Kentucky. Currently, she serves as a professor of neurology and neurocritical care at a university and as an attending neurologist at a university-affiliated medical center in Oregon.