CASE IN POINT
Judgment for the Defense

DIFFICULT DIAGNOSIS OF SPINAL ARTERIOVENOUS FISTULA

The case involved a 50-year-old man with a delay in diagnosis of a spinal arteriovenous fistula (an abnormal connection between an artery and vein near the spinal cord). His symptoms started with sporadic weakness of lower leg muscles. (Fig 1-1)

Fig 1-1 --- Click on Images to Enlarge
Within a couple of months of the initial symptoms, he progressed with further weakness in his legs, as well as urinary retention . He was diagnosed with transverse myelitis (inflammation of the spinal cord), based on his symptom presentation and the films that were taken. The films showed an area of inflammation/demyelination from T6 down to L1 (Fig 1-2). He was treated with a high dose of steroids, and on the 4th day of treatment, he became completely paraplegic (unable to move his lower extremities). Over the new few months he slowly improved during rehabilitation, eventually being able to walk with a rolling walker and to regain bladder control. After a few months of improvement, he once again lost the ability to walk, and his bladder dysfunction returned. A spinal angiogram was performed, showing a spinal arteriovenous fistula at T11 and T12. During the angiogram, the physician was able to close off some of the feeding arteries that went into the venous plexus. A week and a half after the angiogram, the patient underwent surgery to ligate the spinal dural fistula. He has lasting effects with permanent paraplegia and neurogenic bladder (dysfunctional bladder).
Fig 1-2 --- Click on Images to Enlarge

PLAINTIFF'S CLAIM:

The defendants fell below the standard of care by failing to diagnosis spinal arteriovenous fistula when the defendant doctor saw and treated the patient a couple months after he presented with the initial symptoms. If the defendants had diagnosed and performed surgery to remove the fistula sooner, the lasting neurological effects could have been minimized. The patient's permanent paraplegia could have been prevented, and his quality of life would be significantly better.

DEFENSE'S ARGUMENT:

The defendant's initial diagnosis of transverse myelitis was well within the standard of care. MRI films showed inflammation of the spinal cord, which, based on the symptoms, indicated transverse myelitis. The cause of myelitis is not always clear cut, and at the time, there was no indication that an arteriovenous fistula was present. The patient was improving with rehabilitation until a sudden decline in his condition triggered a need for further testing. The defendants then performed an angiogram and were able to diagnose the arteriovenous fistula. At that point, they took necessary actions to ligate and remove the fistula and dilated venous plexus. It is unfortunate that the patient now has permanent paraplegia, but the defendants' actions were appropriate in diagnosis and treatment of his symptoms and condition as they made themselves apparent.

VISUAL STRATEGY:

Collaborating with the defense attorneys and expert witnesses, Illustrated Verdict created a visual strategy to help illustrate the anatomy and the timing of this medically complex case.

The first chart was a timeline of the plaintiff’s symptoms. (Fig 4-1)
Fig 4-1

 
A calendar was created to help the attorneys and expert explain the events when his symptoms became severe after the initial onset of symptoms.
(Fig 4-2)
Fig 4-2
 
The next group of diagrams was normal anatomy illustrations of the spine and vasculature. (Fig 4-3, 4-4, 4-5, 4-6)
Fig 4-3

Fig 4-4
Fig 4-5

Fig 4-6

 
Another diagram was used to show how a spinal angiogram is performed.
(Fig 4-7)
Fig 4-7
 
We created a diagram of a spinal arteriovenous fistula. (Fig 4-8)
Fig 4-8
 
To help educate the jury on the typical signs and symptoms of transverse myelitis, we created the following illustration. (Fig 4-9)
Fig 4-9
 
Experts helped us create visuals to show other case studies of transverse myelitis and their outcomes. (Fig 4-10)
Fig 4-10
 
Another diagram from the expert helps explain what the causes of transverse myelopathy and myelitis can be. (Fig 4-11)
Fig 4-11
 
Example films were used to show how a typical dural arteriovenous fistula appears on an MRI. (Fig 4-12, 4-13)
Fig 4-12

Fig 4-13
 
The plaintiff's MRIs were also displayed from the initial studies to help explain what the doctors were seeing at that time and why they made the decisions they did for tests and rehabilitation. (Fig 4-14, 4-15, 4-16, 4-17)
Fig 4-14

Fig 4-15
Fig 4-16

Fig 4-17

 
The plaintiff's MRI that help lead the doctors to make the decision to do a spinal angiogram, which lead to the diagnosis of an arteriovenous fistula.
(Fig 4-18)
Fig 4-18

 

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

  • The initial diagnosis of transverse myelitis was within the standard of care, based on the patient’s symptoms and response to rehabilitation.
  • Diagnosing an arteriovenous fistula is not a straightforward process. In some patients it takes time and different measures to find out what is causing the transverse myelitis.
  • Once the patient’s condition worsened, the physicians acted appropriately by performing more tests, which ultimately found the arteriovenous fistula.
RESULT:
The jury found in favor of the defense. 

“We were fortunate to reach a defense verdict for an attending neurologist in a medically complex trial about a patient who suffered from an undiagnosed spinal arteriovenous fistula, which led to permanent paraplegia in a young active professional man. The timeline was lengthy and the medical issues were quite involved, requiring accurate yet succinct illustrations to help the jury, the court, and significantly me, understand the medicine and the diagnostic process. Illustrated Verdict staff provided crucial support and advice, and responded to multiple lawyer-made crises with acceptance and hard work. In addition, our radiology expert's testimony depended on reliable court room technology. The judge did not accept any delays gracefully, and Illustrated Verdict went the extra mile to make sure all the hardware was in place, on time, and functioning ensuring a smooth transition and presentation. I'm glad they do what they do, and that they do it so well.”

- Attorney Brian Sullivan, Sloane & Walsh, Boston, MA

 

About Us Case In Point Library