This case involves a young woman with a past medical history of Spina Bifida. Immediately following a ventriculoperitoneal (VP) shunt replacement, she experienced right-sided hemiparesis. Postoperative CT imaging showed that the physician misplaced the VP catheter.

VP shunting is an operative neurosurgical procedure designed to relieve the symptoms of hydrocephalus. A VP shunt is a small plastic tube that helps drain extra cerebrospinal fluid from the brain. Most physicians place VP shunts to treat hydrocephalus. Many patients with Spina Bifida and shunted hydrocephalus will require a VP catheter for life.

The most common problem with shunt placement is blockage and malfunction due to breakage. Roughly 40% of VP shunts will fail and necessitate replacement within one year, with an average of 60% requiring revision within a few years and 80% within 10 years. Approximately 20% of people with Spina Bifida will require more than one shunt revision during their lifetime.

Although ventricular shunt placement is a common neurological procedure, it comes with a relatively high revision rate of 19–33% within 6–12 months of placement. Obstruction and infection are the most common causes of VP shunt malfunction. However, other complications can occur as well, including bowel perforation, pseudocyst formation, and over-draining, which can lead to the formation of a subdural hematoma. Infection, cerebrospinal fluid leak, and intracerebral hemorrhage are also well-understood complications.

Numerous studies have reported the known complications of invasive procedures such as extra ventricular drainage or shunt operation. However, injuries of neural tracts in the brain leading to hemiparesis caused by these procedures have been reported infrequently. Commonly, measures to optimize catheter placement are deemed necessary to reduce risks following ventricular shunt placement.

In this case, negligence in the placement of a VP shunt catheter led to a catastrophic outcome including right-sided hemiparesis.

An expert pediatric neurosurgeon can outline the negligence regarding this VP catheter misplacement that led to right-sided hemiparesis. This expert can speak to causation and the violation of the standard of care.

What are the common measures physicians can take to prevent and manage VP shunt catheter misplacement?

Is hemiparesis a known complication in VP shunt placement?

What is the prognosis for a VP replacement in a Spina Bifida patient?

What effect on medical prognosis does the misplaced shunt have on this Spina Bifida patient?

Here is what the pediatric neurosurgery expert in this case had to say:

In this medical malpractice case, the misplacement of the ventriculoperitoneal shunt catheter led to the patient’s right-sided hemiparesis.

VP Shunt Catheter Misplacement Leads to Paralysis

This case involves a pediatric patient who received regular well-child visits. The mother raised concerns regarding the child’s head size and shape as well as possible neck and skull deformities. In the first year of the child’s life, the mother expressed developmental concerns, which the physician reportedly ignored. About two years later, the child received a diagnosis of cranial deformity along with a prominent brow, abnormal fontanelles, depression of the skull behind the frontal bones, and prominent frontal bones. MRI results revealed hydrocephalus with enlargements of the 4th, 3rd, and lateral ventricles.

For the brain to function properly, the brain must constantly produce cerebrospinal fluid (CSF). CSF cushions the brain inside the skull, acts as a shock absorber, carries nutrients to brain tissues, removes waste, and adjusts brain blood volume. Hydrocephalus occurs when excess CSF accumulates in the brain due to a medical condition that interferes with the flow and absorption of CSF. When CSF builds up in the brain, the ventricles expand, which causes the brain to swell. As a result of excessive fluid pressure against brain tissue, hydrocephalus occurs.

A delayed diagnosis and treatment of hydrocephalus are associated with a higher risk of negative outcomes. Outcomes include developmental delays and permanent brain damage in babies. Early diagnosis and treatment greatly increase the chances of a successful recovery. Early diagnosis allows treatment to begin sooner. Typically, a physician uses a shunt to divert CSF to an area of the body where it can be reabsorbed. This reduces the pressure on the brain.

During the first year of an infant’s life, a physician should measure the baby’s head circumference regularly. If a child’s head circumference increases in an abnormal percentile relative to other infants of the same age, a physician should suspect hydrocephalus.

Hydrocephalus is characterized by an unusually large head and bulging fontanels. The symptoms associated with hydrocephalus include vomiting, excessive sleepiness, irritability, seizures, poor feeding, developmental delay, and muscle weakness.

Medical malpractice may result from failing to diagnose hydrocephalus in infants in a timely manner. In this case, the mother provided ample information for an early diagnosis. The failure to screen is a violation of the standard of care. As a result of the delayed diagnosis, the child continues to have medical needs. Early diagnosis and intervention could have prevented long-term problems.

How might a delay in diagnosis of an enlarged head and reported developmental concerns impact a patient’s future needs in terms of shunt placement and related procedures?

What additional care and sequelae can be expected in this case?

Did a delay in diagnosis permanently affect the child’s future well-being?

What measurements of growth should a physician take at a well-child visit? Is the failure to screen for an enlarged head a violation of the standard of care?

What are some findings on well-child visit measurements that would prompt additional workup or referral?

How should the physician have addressed the mother’s concerns?

An expert pediatric neurosurgeon can review the case and discuss the child’s ongoing shunt needs. This expert can opine on how an earlier intervention might have affected the child’s prognosis.

A physician assistant can opine on the standard of care for diagnosing possible hydrocephalus during well-baby screenings.

A family medicine expert can speak to the standard of care in head circumference screening in infants. This expert can also testify to the need for referral of abnormal findings.

In this medical malpractice case, the physician’s failure to early intervene when the mother raised concerns about the child’s head size resulted in a delayed diagnosis of hydrocephalus.

Failure to Diagnose Pediatric Hydrocephalus Leads to Tragic Results

This case involves a child who had a normal birth. The pregnancy was uncomplicated, and there were no noted hypoxic episodes or needle injuries during delivery.

In the first months of the patient’s life, a resident and an attending pediatrician saw the patient during well-child visits. Neither the resident nor the attending physician took head circumference measurements at any time.

Both the attending physician and the resident failed to properly screen the child. Easily identifiable symptoms went unrecognized. This resulted in a month-long delay in diagnosis. During this time, the child presented with obvious neurological symptoms, and treatment began.

As a result of the delay in diagnosis, the child experienced neurologic deterioration. The child received delayed neurosurgical intervention for the treatment of the condition. Years later, the patient continues to suffer from neurologic sequelae and is showing continued signs of developmental delay.

The case involves allegations that the attending pediatrician and resident pediatrician failed to perform standard diagnostic tests. Furthermore, the attending pediatrician and the resident allegedly failed to diagnose hydrocephalus in an infant. The failure to adhere to the medical standard of care during the outpatient pediatric well-visits, including head circumference measurements, resulted in a violation of the standard of care.

Hydrocephalus is a dangerous medical condition that can lead to brain injury, developmental delay, vision problems, and death. It affects 1 to 2 of 1,000 live births in the U.S. each year. The fluid that continues to build in the brain causes the head to swell and has definable symptoms including increased head circumference, a bulging fontanelle, downward deviation of the eyes, and prominent scalp veins. Most of these cases are diagnosed before birth, at the time of delivery, or in early childhood.

This child suffered a permanent brain injury because the hydrocephalus was allowed to progress without being properly diagnosed, delaying treatment.

What measures do pediatricians perform to screen for, diagnose, and treat hydrocephalus? Is it below the standard of care to not perform these tests?

How important is the timeliness of intervention in hydrocephalus? What effect does a delay in treatment have in patients who develop hydrocephalus in the first months of life?

How common is it to miss a diagnosis of hydrocephalus?

What are the common ocular complications that are caused by a delay and diagnosis of hydrocephalus and would earlier treatment likely make a difference in the outcome of this case?

Is damage caused by delay in diagnosis of hydrocephalus progressive or permanent?

A pediatric physician can speak to the common signs and symptoms of hydrocephalus in children. This expert can also testify to the testing measures used and how often an infant is screened for the condition. A pediatric physician can opine on the standard of care for identifying and diagnosing a possible case of hydrocephalus.

A pediatric neurologist can speak to the brain development damage and future complications that a delay in diagnosis of hydrocephalus can cause.

Pediatric ophthalmologists are regularly consulted in children with hydrocephalus as the risk of developing several eye issues is high. Here, an expert can speak to the risks and symptoms the pediatrician should have looked for and missed.

A physician's failure to provide the standard of care for outpatient pediatric well-visits resulted in a failure to promptly diagnose hydrocephalus.

Undiagnosed Pediatric Hydrocephalus Leads to Developmental Delay

This case involves a pediatric patient diagnosed with myoclonic epilepsy. The physician initially treated the patient with Depakote. However, the patient’s seizures remained uncontrolled. The physician then prescribed the patient Lamictal. Yet, the physician did not remove Depakote from the treatment protocol. Within two weeks, the child developed a rash on his inner thigh and red bumps on his cheek.

The patient’s mother contacted the physician. On the phone, the physician instructed the parent to give the child a steroid. The physician told the parent that the prescription for the steroid will be at the pharmacy. However, the patient’s condition continued to deteriorate. Two days later, the parent took the patient to the emergency room for evaluation. At the hospital, a physician prescribed the child Benadryl along with an additional corticosteroid.

Hours later, the patient’s mother noticed a blister on a portion of the rash. She then contacted a dermatologist who referred her back to the hospital.

Allegedly, there was an hours-long delay in treating the patient upon admission to the emergency room. A physician eventually diagnosed the child with Stevens-Johnson Syndrome. The child then went to pediatric intensive care where he ultimately required intubation. However, the patient continues to experience complications including significant ocular sequelae.

The Lamictal rash is a known warning sign that can lead to Stevens-Johnson Syndrome. Furthermore, it can be fatal and result in ocular damage. The physician should have immediately discontinued Lamictal and put supportive measures in place. Prescribing steroids without examining the child or removing the offending drug was negligent medical management.

A hypersensitivity reaction to the drug caused the Lamictal rash. Moreover, this reaction can trigger a severe medication-induced immune response. These reactions can appear shortly after taking the drug, even several hours or many days later. Standard of care dictates that physicians give patients and caregivers instructions as to this possible complication. Stevens-Johnson Syndrome is medication induced in most cases. Lamictal is an anticonvulsive medication well known to be associated with this adverse reaction. As a result, a black box warning is in place.

Negligent prescribing of Lamictal in a pediatric patient who had recently taken Depakote adds to the risk of the development of Stevens-Johnson Syndrome.

In this case, a failure to timely treat and diagnose signs of Stevens-Johnson Syndrome by the neurologist and the emergency room led to a delay in treatment. The prescribing of additional steroids only and failure to discontinue Lamictal is negligent. The effectiveness of interventions such as corticosteroid use is not conclusive.

Management of Stevens-Johnson Syndrome requires the immediate discontinuation of the inciting medication and supportive care to avoid refractory seizures and complications. Abrupt discontinuation of Depakote can lead to complications. A discharge from the emergency room was negligent as was the prescribing of Benadryl.

Stevens-Johnson Syndrome almost always requires continued medical observation. The complication is very well taught. Moreover, all medical staff should have known about the complication. As such, this patient’s diagnosis should have been immediately identified, and the patient should have been admitted for treatment and observation. The physician should have treated skin damage as a thermal burn.

Ocular manifestations resulting from Stevens-Johnson Syndrome include conjunctivitis, scarring of the conjunctiva, and inflammation inside the eye. Additionally, ocular manifestations also include corneal blisters and the perforation of the eye, which can lead to permanent vision loss

What precautions should the physician have taken when converting from Depakote to Lamictal in young patients with epilepsy?

Should the physician have advised the parent to watch for signs of Stevens-Johnson Syndrome? Should the physician have warned the parent about the possible drug reactions and interactions?

What steps should the neurologist have taken when learning of the rash?

What protocol should have been followed in the emergency room?

Should the physician have ordered the titration of Depakote and discontinuation of Lamictal?

What is the long-term prognosis for this patient?

Should the neurologist and the ER staff have been expected to identify possible Stevens-Johnson Syndrome?

Pediatric neurologists specialize in childhood epilepsy, diagnosis, and proper prescribing. An expert neurologist can speak to the violation of the standard of care here. This expert can also testify about the proper medical course of action in a child experiencing uncontrolled seizures.

Pediatric optometry experts specialize in diseases of the eye. These experts can speak to the treatment for damage caused by Stevens-Johnson Syndrome.

Emergency room expert physicians can speak to the common knowledge of Stevens-Johnson Syndrome, negligence, and the common standard of care.

In this case, the physician allegedly gave a negligent overdose of Lamictal to a pediatric patient who was also taking Depakote. There was also an alleged failure to timely diagnose Stevens-Johnson Syndrome in the emergency room.

Delay in Diagnosis of Stevens-Johnson Syndrome Damages Child’s Vision

A Minnesota firm wins a case for a boy thrown over the railing at a large shopping mall, aided by a top neuropsychologist from Harvard; detailed reports secure settlement, avoiding trial trauma.

A Minnesota personal injury firm with experience in catastrophic brain damage cases represented the family of a young boy thrown over a railing at a large shopping mall. The boy’s mother, the child, and a young friend had gone to the mall for a little celebration after a nice preschool parent-teacher conference. The fun, festive afternoon quickly turned into a nightmare.

Out of the blue, a stranger grabbed the boy and hurled him over a third-floor balcony where he landed on the tile floor below. The troubled man who did this had been banished from the mall for earlier problems. Yet somehow, he was allowed in on that fateful day.

After the forty-foot fall, the poor child 

 multiple life-threatening injuries including skull fractures, broken arms, and a broken leg. After being cared for in a hospital for several months, the boy had nothing short of a “miraculous” recovery, with some limitations. He even made it to his first day of kindergarten after being discharged just in time.

With how far he fell, it was amazing he even survived. Although it was presumed the child would have no long-lasting cognitive, memory, or trauma-related problems, the attorneys wanted a pediatric neuropsychologist to evaluate him and his future care needs.

Not only did the Expert Institute find an excellent pediatric neuropsychologist – she was also local! The lawyers for the family felt that if the case had gone to trial this would have been very positive with a local jury.

The firm was exceedingly happy with the neuropsychologist the Expert Institute identified for the case. The expert had founded a pediatric neuropsychology clinic in Minnesota where she was the clinical director. It gets better – her credentials also included a fellowship in child neuropsychology at Harvard Medical School. With her experience in kids’ brain injuries, this hand-picked expert efficiently reviewed the medical records, examined the child multiple times during the case, and provided extremely detailed periodic reports to the firm.

The neuropsychologist described in depth what the boy’s condition was and what his future limitations might be. The firm was so impressed with how detailed the expert’s reports were and how good she was at helping the lawyers and the family understand his condition. “She went above and beyond what most experts would do.”

Using the information and insights from discussions with the medical expert, the firm’s damages expert mapped out a life care plan for the boy. The lawyers were ultimately able to negotiate a settlement for this sensitive case, sparing the family and the child the ordeal of a trial.

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Pedatrics Posts

Pediatric Neuropsychologist Couldn’t Have Been More Perfect for a Family’s Confidential Personal Injury Case

VP Shunt Catheter Misplacement Leads to Paralysis

Failure to Diagnose Pediatric Hydrocephalus Leads to Tragic Results

Undiagnosed Pediatric Hydrocephalus Leads to Developmental Delay

Delay in Diagnosis of Stevens-Johnson Syndrome Damages Child’s Vision

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