CASE IN POINT
Judgment for the Defense

DELAY IN DIAGNOSIS OF CHIARI I MALFORMATION

The case involves a young boy who suffered from years of disabling headaches. By the time he was 13 years old, he had suffered from recurrent headaches twice a week for at least two years, with the following associated symptoms: photophobia, phonophobia, and vomiting. Later that year, he had an MRI that was read as normal. He was treated with multiple medications to help with the migraines. The next year, he started seeing the defendant physician, a pediatric neurologist. He continued to have daily migraines, and the defendant physician continued to prescribe medication to help alleviate his symptoms. The defendant physician also emphasized to the patient the importance of a regular sleep pattern, increased water intake, and consumption of regular meals with an increased variety of foods. The defendant physician treated the patient for just under a year. More than a year later, he had another MRI of the brain that was also read as normal. Another year passed with the same symptoms, so the patient underwent another MRI, from which he was diagnosed with "borderline cerebellar tonsillar ectopia (Chiari I malformation)." A few days after diagnosis, he underwent a sub-occipital craniectomy (Fig 1-1) and C1 (cervical vertebra 1) laminectomy for the cerebellar tonsillar ectopia. The surgeon found a 3mm tonsillar herniation.

Fig 1-1 --- Click on Images to Enlarge

Post-operatively, the patient continued to have headaches and was eventually diagnosed with failed Chiari surgery with pseudomeningocele (Fig 1-2) formation and persistent tonsillar herniation. He had a ventriculoperitoneal shunt (Fig 1-3) placed to remove fluid from around his brain and spinal cord. After the shunt was removed, his physicians continued to monitor him, but his headaches were never relieved by any medications or procedures.

Fig 1-2
Fig 1-3

PLAINTIFF'S CLAIM:

The defendant's care fell below the standard of care because he did not diagnose what plaintiff alleged was a Chiari I malformation (Fig 2-1) and failed to treat the plaintiff sooner for this condition to help relieve his headaches.

Fig 2-1

DEFENSE'S ARGUMENT:

The defense wanted to focus on the fact that the MRIs were normal studies with no hydrocephalus (Fig 3-1) or ventriculomegaly and that the cerebellar tonsils never descended to 5 mm or more. Typically, for a diagnosis of Chiari I Malformation or for surgical intervention to be indicated, the cerebellar tonsils should be 6mm or more lower than the foramen magnum (the opening at the base of the skull). None of the studies performed explained the boy's chronic headaches, which they believed were psychogenic in origin. Also, the multiple procedures he had after the diagnosis provided no relief from his headaches and other symptoms.
Fig 3-1

VISUAL STRATEGY:

Collaborating with the defense attorneys and experts, Illustrated Verdict created a visual strategy to help illustrate the anatomy of the cerebellar tonsils, supporting the view that the defendant's diagnosis and treatment were within the standard of care.

The first and second diagrams selected illustrated the anatomy of the brain and specifically the tonsils of the cerebellum. (Fig 4-1, 4-2)
Fig 4-1

Fig 4-2

 
Next, a diagram was selected to show the anatomy of the opening at the bottom of the skull, the foramen magnum.(Fig 4-3)
Fig 4-3
 
Another normal anatomy diagram was used to show the relationship of the tonsils of the cerebellum to the foramen magnum. (Fig 4-4)
Fig 4-4

 
Stock images of the brain and tonsil herniation were chosen to show the difference between normal anatomy and a cerebellar tonsil that has moved through the foramen magnum at the bottom of the skull. (Fig 4-5, 4-6)
Fig 4-5
Fig 4-6
 
We then created two diagrams to explain how Chiari I malformation is diagnosed in patients, with a protrusion of the cerebellar tonsils at least 6mm beyond than the foramen magnum. (Fig 4-7, 4-8)
Fig 4-7
Fig 4-8
 
It was also important to illustrate how CSF (cerebral spinal fluid) circulates around the brain to demonstrate that there was no need for surgical intervention in this case. (Fig 4-9)
Fig 4-9
 
The next diagram was used to show that if there was a severe Chiari I malformation, hydrocephalus and ventriculomegaly would have been found on the MRIs due to blocked CSF flow down the spinal cord and increased pressure within the skull. (Fig 4-10)
Fig 4-10
 
Many films were used in this case to help illustrate that the MRIs were within normal limits and were not read incorrectly. The first few were example films that were used to help the jury understand what a true Chiari I malformation would look like on an MRI. (Fig 4-11, 4-12)
Fig 4-11
Fig 4-12
 
We color-enhanced one of the example films to highlight for the jury the relevant anatomy and show that in a Chiari I malformation, the tonsil protrudes quite far into the spinal canal.(Fig 4-13)
Fig 4-13
 
Color enhancements were also created from the plaintiff's films as well, from three different MRIs. These helped demonstrate that the cerebellar tonsils never were past the 5mm mark that would be cause for concern. (Fig 4-14, 4-15, 4-16, 4-17)
Fig 4-14
Fig 4-15
Fig 4-16
Fig 4-17
 
Full sheets of the MRI films were also used to show that there was no evidence of hydrocephalus and ventriculomegaly. (Fig 4-18, 4-19, 4-20)
Fig 4-18
Fig 4-19
Fig 4-20

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

  • The cerebellar tonsil and foramen magnum anatomy involved in diagnosing a Chiari I malformation.
  • There were no signs of hydrocephalus or ventriculomegaly on the plaintiff’s MRIs.
  • The films clearly show that the tonsils were not protruding further than 5mm for them to consider a Chiari I malformation diagnosis.
RESULT:
The jury found in favor of the defense. 

“We won the case. The illustrations were great! Look forward to working with you in future cases.”

- Attorney Charles L. Bach, Jr., Heidell, Pittoni, Murphy & Bach, LLP, New York, NY

 

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