Trivent Neurologist Identifies Deviations from Standard of Care in Cerebral Venous Thrombosis Case

A 25-year-old patient who was brought to the emergency department via ambulance with complaints of right-sided numbness and weakness.  Trivent MD identified several deviations from the standard of care in this case.

Trivent Review : 

Despite a diagnosis of functional movement disorder and conversion disorder, the patient continued to experience abnormal movements. Lab work and a head CT scan were unremarkable and she had some improvement in her anxiety after Ativan. The patient was discharged with a recommendation for outpatient follow-up with a primary care physician and psychiatry, as well as physical therapy and occupational therapy.

However, the very next day, the patient was found to have an extensive venous sinus thrombosis. She was admitted to the intensive care unit and began treatment with heparin. Neurosurgery was called, and an EVD was placed to treat hydrocephalus. The patient’s mental status deteriorated rapidly, leading to acute encephalopathy.

Our Neurologist determined that there was a deviation from the standard of care in this case. The patient’s psychiatric history and improvement in symptoms following Ativan administration should have prompted further evaluation and consideration of risk factors. The delay in diagnosis and timely management resulted in rapid cognitive deterioration and acute encephalopathy.

Some of the deviations noted in this review include:

• Failure to fully investigate the cause of the patient’s clinical presentation
• Failure to consider risk factors in the diagnosis
• Failure to recommend further evaluation
• Failure to admit the patient considering the clinical presentation.

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