An insight into The Skeleton Series: Week 3 – Neurosurgery & Neuroradiology

7BR’s six week set of medico-legal seminars, known as The Skeleton Series, is in its ninth year. For anyone practicing in Clinical Negligence they are a must attend event at the start of the calendar year, providing you with undoubtedly some of the most valuable CPD points on offer in this area. You are given the opportunity to hear from some of the leading surgeons, consultants and professors of medicine in the country, alongside expert lawyers at the top of the field. For anyone who has not experienced one, below Leslie Keegan, Barrister at 7BR, runs through the session he spoke at in week 3 of the series.

Week 3 was a fascinating evening in the 2016 series. Chairing the session was Hugh Preston QC; ranked as a leading silk by both Chambers and Partners and Legal 500 Hugh is currently instructed on the PIP Breast Implant Group Litigation – recently placed at the top of The Lawyer’s top 20 cases in the pipeline for the year ahead.

The evening started with an entertaining and highly informative lecture given by Mr. Nick Todd, a Consultant Neurosurgeon. Mr. Todd opened his lecture by explaining what a subarachnoid haemorrhage is, what its causes are and how it can be detected.

Mr. Todd explained that subarachnoid haemorrhage is one type of spontaneous intracranial haemorrhage. The majority of subarachnoid haemorrhages are caused by an aneurysm which is a “balloon- like” dilatation of an intracranial artery.  The wall of an aneurysm is weaker than a normal blood vessel wall, which predisposes it to rupture causing bleeding, which is initially into the subarachnoid space.

Approximately one-third of patients die before reaching medical care. The overall mortality can be as high as 40-60% and approximately 80% of those patients who die will die within 24 hours of the initial subarachnoid haemorrhage.

Mr. Todd told us that the most common and important presenting feature of subarachnoid haemorrhage is the abrupt onset of severe headache. This characteristic should be taken seriously as the failure to diagnose an initial subarachnoid haemorrhage will commonly be associated with re-bleeding which is associated with a high mortality and morbidity. Headache typically occurs abruptly i.e. it is of sudden onset, quite different from a patient’s previous experience of recurrent or persistent headache. The headache is typically severe: the patient will typically say that this is the worst headache that they have ever experienced; some patients report that they thought they had been punched in the head. The abrupt onset of severe headache must be considered to be caused by subarachnoid haemorrhage until proven otherwise.

Mr. Todd stated that one-third to one-half of patients will report severe headache in the preceding days or weeks; this represents a non-catastrophic leak and has been termed sentinel haemorrhage although it does represent the first episode of aneurysmal haemorrhage.

Other symptoms include nausea and/or vomiting, neck pain and/or photophobia. However more than 50% of patients have none of these symptoms and the absence of such symptoms does not exclude the diagnosis. The signs of subarachnoid haemorrhage are those of meningeal irritation, photophobia and/or neck stiffness. These physical signs are not present in 50% of patients and their absence does not exclude the diagnosis of subarachnoid haemorrhage.

Mr. Todd explained that rupture of an intracranial aneurysm can result in haemorrhage into the subarachnoid space alone. Aneurysmal subarachnoid haemorrhage can also lead to bleeding into the subdural space (a subdural haematoma), bleeding into the parenchyma of the brain (intracerebral haematoma) and/or bleeding into the ventricular system (intraventricular haemorrhage). The symptoms and signs of the primary and/or subsequent haemorrhage can therefore include altered consciousness and/or a variety of focal neurological deficits which depend upon the site or sites of a haematoma.

Mr. Todd told us that the first investigation of SAH should be CT imaging of the head. It appears that this will demonstrate a SAH in 93% of patients imaged within the first 24 hours of subarachnoid haemorrhage. As time passes blood is gradually removed from the subarachnoid spaces.  The sensitivity of CT imaging is therefore reduced to 80% at 72 hours.  Blood is rarely identified beyond three weeks.

Mr. Todd stated that if the CT scan is negative a lumbar puncture should be performed. The lumbar puncture may demonstrate either frank blood or the breakdown products of blood. If the CT scan and the lumbar puncture have failed to demonstrate subarachnoid haemorrhage then the diagnosis of subarachnoid haemorrhage is excluded.

There are two forms of treatment to prevent re-bleeding from intracranial aneurysms, the first is microsurgical clipping, and the second is endovascular coiling. Microsurgical clipping was previously the treatment of choice and if successful the aneurysm is completely and permanently excluded from the circulation and the risk of re-bleeding is very low. Aneurysm coiling is performed by an interventional neuroradiologist.

Expert Two

Dr. Andrew Molyneux, a Consultant Interventional Neuroradiologist then went on to tell us just what aneurysm coiling is and how it is carried out. Aneurysm coiling is performed by an interventional neuroradiologist. A microcatheter is guided to the neck of the aneurysm following which detachable coils are placed into the aneurysm to exclude the aneurysm from the circulation.

Both Mr. Todd and Dr. Molyneux told us about the ISAT trial. The first prospective randomised trial comparing aneurysm clipping and endovascular coiling was the International Subarachnoid Aneurysm Trial (ISAT), the results of which were published in 2002. The trial design required “clinical equipoise” in management i.e. the treating doctors felt that the aneurysm could be treated either by clipping or coiling.

The benefit to survival in patients who were coiled compared to those who were clipped has been maintained to a mean follow-up of 7 years. Coiling may not completely remove the aneurysm from the circulation, i.e. there may be a neck remnant. Over time the coil ball may pack down, exposing part of the aneurysm to the general circulation. There is a risk of re-bleeding from coiled aneurysms which is probably around 0.13%12. Repeat coiling will be required in 1-20% of patients; re-treatment was required in approximately 10% of the ISAT patients.

Coiling and clipping are complimentary treatments. In the UK, where an aneurysm can be coiled, treatment with coiling is usually recommended as the initial treatment.

Dr. Molyneux also informed us that the major cause of errors which gives rise to claims is in cases of missed aneurysms and delayed diagnosis. Dr. Molyneux stated All patients with a confirmed SAH should be transferred to Neurosurgical care ASAP (same day or next day at latest); there should be prompt investigation for the presence of an aneurysm and there is a need to exclude an aneurysm as the cause. (100% certainty of no aneurysm). Patients should have the aneurysm secured with 48 hours of SAH. NCEPOD report “Managing the Flow” 2013.

Closing The Evening

Overall it was a fascinating insight into the diagnosis and treatment of SAH and they both generously referred to the case that Derek Sweeting QC and I were involved in late last year and where Mr. Todd and Dr. Molyneux gave us invaluable assistance in reaching a successful conclusion to the case

I then concluded the evening with a session on my successful request to the High Court to exercise the inherent jurisdiction in order to protect a client who had been assessed by the experts as having capacity but who was clearly in a vulnerable position. I traced through the history of the inherent jurisdiction and in what type of cases the Court had grated protection to vulnerable individuals who had capacity. I explained the steps required to do this; what a Harbin v Masterman order is; and provided an example of a model order to put before the court. The session generated a great deal of interest and I have since had many discussions with solicitors regarding when it is possible to use this and just how it is achieved.

Next year is the tenth anniversary of the series and with planning already underway it’s sure to have as enticing a line-up of speakers as in previous years. To find out more on the series or be added to the mailing list for news on 2017 places and tickets, please email rsvp@7br.co.uk with Skeleton Series in the title.

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