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.
www.illustratedverdict.com

 

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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
Vertebral Artery Dissection with
Coil Embolization

The case involves a car accident causing a C2 fracture and vertebral artery dissection in a 51-year-old woman. The defendant, a neurosurgeon, decided to treat the dissection with a coil embolization. During the course of the procedure, a piece of existing thrombus in the left vertebral artery fractured off and traveled into the right posterior cerebral artery (PCA) of the brain. Several attempts were made at mechanical retrieval, first using a Merci micro catheter, and then tissue plasminogen activator (tPA) administered directly at the clot through a micro catheter, all unsuccessfully. One additional attempt was made with mechanical retrieval, again without success. After this last attempt, an extravasation was noted in the area of the PCA; as such, the procedures were terminated. The patient went on to suffer a significant stroke with serious neurological residuals.

 

PLAINTIFF'S CLAIM:

The defendant negligently failed to treat the thrombus in the P2 segment of the right PCA, leading to an acute infarct involving the right occipital lobe, right thalamus, mid-brain on the right, and posterior right temporal lobe with some mild mass effect. The patient went on to suffer multiple serious neurological residuals due to this stroke.

 

DEFENSE'S ARGUMENT:

The patient was stable during the coil embolization and tolerated the procedure well. When the occlusion in the PCA was discovered after the successful coil embolization procedure, the defendant acted appropriately by making multiple attempts to retrieve the clot, using a Merci retrieval device and tPA infusion. After these attempts were unsuccessful and a small amount of extravasation of contrast was noted, the defendant appropriately terminated the procedure.


VISUAL STRATEGY:

Collaborating with the defense attorney, Illustrated Verdict created a visual strategy to help illustrate the relevant anatomy and the plaintiff’s injury, and to explain the steps taken in the care of the plaintiff, supporting the view that the defendant’s actions were within the standard of care.

 

The initial three diagrams illustrated the anatomy of the head and neck to orient the jury to the vertebral arteries in anterior, posterior/lateral, and lateral views.


Next, a diagram was created to show the C2 fracture with vertebral artery dissection and thrombus.


The fifth and sixth diagrams were used to show what a dissection looks like in an artery and the process of dissection.

 

The next diagram illustrated the coil embolization procedure used to treat the vertebral artery dissection.

 

An eighth diagram showed the clot subsequently seen at the P1-2 segment of the right PCA.


Finally, a ninth diagram was created to illustrate a representation of the Merci retrieval process used to try and remove the PCA clot.

In addition to the illustrations, the defense used enlargements of some of the pertinent images from the CTA study from the date of the surgery.

 

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

  • The patient was stable throughout the procedure.
  • The defendant properly monitored the patient during the procedure and reacted in an appropriate manner when the P2 embolus was discovered by attempting retrieval with the Merci micro catheter and tPA multiple times.
  • Once attempts at mechanical and chemical removal of the P2 embolus were unsuccessful and the small extravasation of contrast was noted, the defendant reacted appropriately by terminating the procedure and immediately transferring the patient for neurosurgical care and neuro-intensive care in the neuro ICU.

 

RESULT:
The jury found in favor of the defense. 

“The case was tried to a conclusion with a finding of no negligence against the MD and the visuals were very helpful.”

- Attorney David Donohue, Farkas & Donohue LLC, Florham Park, NJ