Description of Event or Problem · 0
FINDINGS: THIS PATIENT WAS A (B)(6) YEARS OLD WOMAN WHO WAS REFERRED TO DR (B)(6) FOR ENDOVASCULAR TREATMENT OF A 9MM BASILAR TIP ANEURYSM. THE INTENT WAS TO DO STENT ASSISTED COILING. THIS PATIENT HAD PRIOR HISTORY OF COPD AND LUNG CANCER WITH LONG TERM SURVIVAL EXPECTATION. THE PATIENT WAS PREMEDICATED WITH PLAVIX AND ASPIRIN PRIOR TO THE PROCEDURE AND WAS ANTICOAGULATED DURING THE PROCEDURE FOR STENT ASSISTED COILING. DURING PLACEMENT OF A MICROCATHETER (FOR ACCESS FOR STENT PLACEMENT) BUT PRIOR TO STENT DEPLOYMENT THE ANEURYSM RUPTURE. (THE OPERATOR INDICATES THAT THE MICROCATHETER AND WIRE WERE NOT IN THE ANEURYSM. THERE WAS NOTHING UNUSUAL ABOUT THESE DEVICES.) THE OPERATOR (DR (B)(6)) REVERSED THE HEPARIN WITH PROTAMINE AND PERFORMED A STENT ASSISTED COILING. DURING THIS TIME BLOOD FLOW TO THE POSTERIOR FOSSA WAS NOT DETECTED (INTRACRANIAL PRESSURE EXCEEDING BLOOD PRESSURE). DR (B)(6) WAS CALLED FOR EMERGENT PLACEMENT OF A VENTRICULOSTOMY. AFTER THE PROCEDURE WAS COMPLETED, IT WAS NOTED ON CT AND MRI THAT THERE WAS EXTENSIVE SUBARACHNOID HEMORRHAGE AND BRAIN DAMAGE. THE PATIENT WAS DISCHARGED TO HOSPICE 11 DAYS LATER AND SUBSEQUENTLY EXPIRED.