Medical Malpractice Insights: Sentinel headache and missed cerebral aneurysm

Author: Chuck Pilcher, MD, FACEP (Editor, Med Mal Insights) // Editors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome to this month’s case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Sentinel headache and missed cerebral aneurysm

Talk to your radiologists, even if you’re a radiologist

Facts: An adult female with a strong family history of cerebral aneurysms presents to the ED with sudden onset of headache. An MRA shows a 4×4 mm focal dilatation of a cerebral artery. The radiologist recommends a CTA to further characterize the suspicious lesion. That study is read by a second radiologist who is unaware of the MRA result. He reports the CTA as normal. The patient is reassured and discharged. The aneurysm ruptures 2 years later, causing a stroke with major disability despite surgery. The prior CTA is reviewed, and the discrepancy discovered. A lawsuit is filed against the radiologists, the ED physician, the hospital, and all other involved physicians.

Plaintiff: You suspected from the MRA that I had an aneurysm. You ordered more tests. You failed to communicate – all of you. You didn’t compare the studies or have a system in place to follow up on my situation. Now I’m unable to function and can’t work.

Defense: You’re right. We realize that now. We made a mistake.

Result: Settlement for an undisclosed amount against only the hospital and its employed radiologists. The plaintiff’s own experts agreed that the ED physician and all others involved acted appropriately based on the information they were provided with by the radiologists and were thus dismissed from the suit. 


  1. Assure that systems are in place to identify and follow up on discrepant or discordant results.
  2. Consider the clinical context and your pre-test probability. If you ordered a test for a good reason, be skeptical if the result is “too good to be true,” especially in a patient with typical history and exam.
  3. Viewing the imaging you order is not only educational but adds a second set of eyes to decrease the chance of a “miss.”
  4. Communicate with your radiologists when the imaging results are inconsistent or unexpected, especially in life and death situations.
  5. A test alone is rarely if ever 100% reliable.
  6. Even if you have a defense for ordering the right tests but having someone else report the wrong results, you will still be involved in a stressful lawsuit for several years.

Reference: Brain (Cerebral) Aneurysm Imaging. Medscape eMedicine. Vinas C. Updated Nov 27, 2018.


Of course, I think that people are just waiting for that time when I make a mistake and they’re gonna jump on it…. There’s gonna be haters.

Justin Bieber

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