IV Case in Point
Illustrated Verdict shares case examples from our archives to show how a visual strategy can support the defense effort. We hope that it is of value in your practice as you develop your defense strategies on behalf of health care providers. Please feel free to forward it to colleagues or clients.

About Us
IV is a leading provider of demonstrative evidence for the defense of medical malpractice claims. Our team of medical illustrators consults with defense teams to educate the lay jury audience about the complexities of medical care. We do this by developing a visual strategy with expert witnesses including high-quality case-specific medical illustrations, x-ray enhancements, and multimedia presentations. IV receives judgment for the defense in over 94% of the cases we participate in, as compared to the national average of 73%. Additionally, insurers who supply us with their trial list enjoy a win rate of up to 97%.
To learn more, e-mail us or call 617-530-1001.
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Case In Point Library
Click to view other editions:

Case In Point Library Page

Pregnancy and Delivery:
Fetal Assessment 2009v1
Shoulder Dystocia 2009v3
MVA Leads to Fetal Demise 2010v4
Fetal Descent Stalled 2010v5
Shoulder Dystocia / Erb's 2011v4
Fetal Tracings / Hypoxic Injury? 2013v1

Heart:
Coronary Artery Disease 2009v5
CAD / Recurrent MI 2010v1
Aortic Valve Replacement 2011v1

Lungs:
Stroke After Lung Surgery 2009v2
PE / Infection 2010v3
PE Following Roux En Y 2012v1
Intubation / Macklin Effect 2012v4
Lung Cancer vs. Infection 2015v3

Female Pelvis:
Hysterectomy / Fistula 2011v9
Hysterectomy / Ureter Injury 2010v2
Hysterectomy / Kinked Ureter 2010v8
Diag Lap / Bowel Injury 2012v3
Cervical Cancer 2013v3
Endometrial Cancer 2014v1

Male Pelvis:
Bladder Cancer 2013v2

Digestive System:
Gastric Bypass 2009v6
Recurrent Hiatal Hernia 2009v8
Right Colectomy / Leak 2010v7
Gastric Bypass / Volvulus 2011v2
Nissen Fundoplication 2011v3
Large Hiatal Hernia 2013v5
Necrotizing Enterocolitis 2013v7
Arrest during ERCP 2015v4
Diverticulitis Complications 2015v5

Abdomen:
Spleen Injury and Bleed 2009v4
Bleed Following Lithotripsy 2012v2
Lap Cholecystectomy 2012v5
Bowel Injury Lap Ovarian Cyst Removal 2013v6
LapChole - Hepatic Duct Injury2015v1

Orthopedic:
Partial Hip Replacement 2010v6

Vasculature:
tPA Infusion 2009v7
Vertebral A. Coil Embolization 2015v7

Head and Neck:
Bell's Palsy 2013v4
Tongue Cancer 2014v2
Chiari I - Vision Loss 2015v2

Judgment for the Defense
Chiari I Malformation - Restricted Vision

In 1997 a 17-year-old woman was diagnosed with pseudotumor cerebri (also called idiopathic intracranial hypertension), a cerebral spinal fluid (CSF) disorder, where CSF pressure inside the skull increases for no obvious reason. She suffered headaches and vision loss in January, 1997, associated with her increased intracranial pressure (ICP). At that time, she suffered damage to her optic nerves that restricted vision in both of her eyes, especially her peripheral vision. She was treated with bilateral optic nerve fenestration, which was unsuccessful, and a lumboperitoneal (LP) shunt (from lumbar spine to peritoneal cavity in abdomen), which helped her recover a 10-degree visual field in each eye.

Ten years later, in May of 2007, she was admitted to the hospital complaining of headaches, having been in a motor vehicle accident a few months previously. Following an MRI, she was diagnosed with a Chiari malformation, where the cerebellar tonsils move below the opening at the base of the skull. Her physicians also concluded that there was a restriction of CSF flow due to a malfunction of the previously placed LP shunt. The LP shunt was removed and a ventriculoperitoneal shunt (from ventricles in brain to the peritoneal cavity in abdomen) was placed.

In early June, she was readmitted for headaches, and a CSF leak with fluid accumulation was found in the lumbar region fatty tissue, where the previous LP shunt had been removed. She was treated for low intracranial pressure and placed in the Trendelenburg position. She still complained of headaches and loss of vision. An intracranial pressure monitor was placed, and her intracranial pressure was found to be elevated at 60mm Hg. She underwent an emergent decompressive suboccipital craniectomy to help relieve the pressure caused by the Chiari malformation. She ended up losing her vision in her left eye (light perception only), while the right eye recovered to approximately the previous 10 degree severely limited field of view.

 

PLAINTIFF'S CLAIM:

The plaintiff claimed that in May of 2007 she was misdiagnosed with low intracranial pressure, when in fact, she was suffering from increased intracranial pressure. The plaintiff also claimed that the surgeon misplaced the ventriculoperitoneal (VP) shunt, failed to recognize that the VP shunt wasn't working properly, and delayed the repair, resulting in an increase in intracranial pressure and further damage to her optic nerves with vision loss. The plaintiff believed that the Trendelenburg position (a treatment for low intracranial pressure) caused additional damage to her optic nerves, because at the time the patient actually had high intracranial pressure, which should have been tested for and identified before she was placed in the Trendelenburg position.

 

DEFENSE'S ARGUMENT:

The defendants presented with an unusual and complex case. The defense experts believed that the defendants properly diagnosed low intracranial pressure when the patient was admitted in May of 2007. The worsening headaches were correctly attributed to her Chiari malformation, which is common when dealing with a LP shunt. The defense also believed that the VP shunt was properly placed, the good return of CSF at the time of the surgery would not have been possible unless the tip of the shunt was properly placed within the ventricle. Defense experts believed the patient’s intracranial pressure increased after her admission in June, and not in May as the plaintiff claimed. According to the defense, the patient’s visual decline occurred during the June admission, which was when the physicians found the increased pressure and performed the decompressive craniectomy surgery.


VISUAL STRATEGY:

Collaborating with the defense attorneys and the defendants, Illustrated Verdict created a visual strategy to help illustrate and explain the plaintiff’s conditions and the multiple procedures the plaintiff had undergone. Also, an exhibit was created to help the jury understand what the plaintiff’s visual field looked like prior to her issues in 2007.

 

The initial diagram illustrated the normal anatomy of the cerebral spinal fluid system to help orient the jury.

 

The second diagram illustrated how an optic nerve fenestration is performed to help relieve pressure on the optic nerves.

 

The next diagram showed the location of a lumboperitoneal shunt, similar to what the defendants had placed in 1997.

 

Another illustration showed the new ventriculoperitineal shunt placed in May of 2007, after her LP shunt malfunctioned.

 

The fifth diagram was a film color enhancement of the MRI from May of 2007 to show the Chiari malformation.

 

The sixth diagram showed how the Chiari malformation could have caused injury and swelling of the optic nerve.

 

Another illustration showed the suboccipital decompression surgery.

 

The final diagram showed the plaintiff’s 10-degree field of vision after the initial injuries to her optic nerves in 1997.

 

This series of visuals helped the defense successfully convey the following key points to the jury:

  • The defendants worked within the standard of care, diagnosed the patient correctly as her symptoms presented, and reacted with the correct procedures.
  • The patient’s anatomy was complicated with a history of pseudotumor cerebri and a Chiari malformation.
  • The patient had significant pre-existing visual loss, with only a 10-degree visual field after her first episodes of pseudotumor cerebri 1997. She did have additional vision loss in 2007, but she was already severely limited.

 

RESULT:
The jury found in favor of the defense. 

“Verdict for the defense! Thank you again for all of your help. The illustration on field of view was extremely useful in our expert’s testimony.”

- Attorney Matt Blackman, Ruprecht, Hart, Weeks & Ricciardulli, LLP, Westfield, NJ