ER Physicians Fail To Diagnose Stroke Following Facelift

    Stroke Expert

    This case involves a 51-year-old female patient who underwent a facelift. She was discharged from the outpatient surgical facility without issue. However, several hours after her operation, she began to experience neurological symptoms including weakness, eyelid drooping, and inability to walk. She called 911 and was found by EMS to be in hypertensive urgency. The patient was brought by ambulance to a local emergency room and a CT scan was ordered stat. The stat CT was canceled however because the patient’s symptoms were attributed to a scopolamine patch. The patient was kept in the emergency room overnight for observation. In the middle of the night, a physician’s assistant became concerned about the patient’s symptoms. The patient then underwent a stat CT scan and further neurological imaging which revealed an embolic cerebral vascular accident. An expert neurologist with specific expertise in vascular disease was sought to opine on managing a facelift patient who presents with postoperative neurologic sequelae.

    Question(s) For Expert Witness

    • 1. Please describe your experience in diagnosing and managing patients with neurovascular disease.
    • 2. What are some of the postoperative neurologic sequelae that a patient might experience following a facelift?
    • 3. What are some of the modalities used in neurological work up of patients with suspected CVA.

    Expert Witness Response E-010203

    I am board-certified in vascular neurology (stroke), and I directed a comprehensive stroke center in New England for almost 15 years. I am initiating a neurohospitalist division at a regional neuroscience institute. About 60% of my clinical practice is based in the hospital, largely in the care of acute stroke patients who are admitted to our neurology residents’ teaching service at a well-known university. We also staff a vascular neurology fellowship at our major teaching hospital. As for this case, typically these patients are coming out of general anesthesia. Because they will initially be sedated, it makes diagnosing a stroke initially a challenge. They are also often subjecting to controlled hypotension by the anesthesiologist in order to minimize bleeding in the operative field. Patients who have just had surgery are at a modestly elevated risk for ischemic stroke also because longterm blood thinners are generally held a few days prior to surgery. The common non-invasive modalities are head CT and brain MRI scans, and their associated tests to assess the arterial treat, CT and MR angiography.

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