Unclear Medication Instruction for Dental Procedure Leads to Stroke

Case Overview

This case revolves around an adult patient who was under a dentist’s care for tooth extraction surgery. The patient had been prescribed Xarelto, a blood thinner, due to Atrial Fibrillation.

The dentist, aware of the patient’s medication, sought medical clearance from the cardiologist managing Xarelto treatment. However, the dentist failed to specify that the three teeth extractions would be performed separately over several days or weeks.

Following the cardiologist’s instructions, the patient ceased taking Xarelto 48 hours before the procedure. Unfortunately, no recommendations were provided regarding when to resume medication. Shortly after this, the patient suffered a posterior inferior cerebellar artery (PICA) stroke and was subsequently diagnosed with right homonymous hemianopsia and photopsia among other sequelae.

Questions to the expert and their responses

What is your experience with PICA stroke cases?

In my nearly 28 years as a neuro-ophthalmologist, I have evaluated numerous patients suffering from strokes similar to PICA strokes. I see such cases several times per month.

What is the protocol for Xarelto patients, and potential complications?

To determine a patient’s visual field deficits and their cause, as well as their prognosis and future care needs, I rely on formal testing using the Humphrey analyzer in my clinic. Additionally, a thorough review of neuroimaging and medical history is crucial.

Have you ever reviewed a similar case? If yes, please elaborate.

Over my extensive career in neuro-ophthalmology, I have reviewed numerous cases involving vision loss due to various causes including trauma, infection, stroke, neurological disease, and injury.

About the expert

This expert is a seasoned neuro-ophthalmologist with over two decades of experience in the field. They have completed extensive education and training, including a residency in ophthalmology and a fellowship in neuro-ophthalmology at renowned medical institutions. Currently serving as a neuro-ophthalmologist for a local vision group and an attending physician at a regional surgical center, they bring significant expertise to the case, particularly regarding conditions like PICA strokes and their impact on vision.