A huge sense of relief washed over Brad Chesivoir when a Maryland emergency room doctor told him the good news: He had not suffered a heart attack or a stroke, as he had feared. Instead he was being discharged with a diagnosis of headache, although doctors weren't sure of its cause.
Several hours earlier, on the day after Thanksgiving 2013, Chesivoir's family had summoned an ambulance to their home after he became suddenly weak and unable to walk. But by the time he got to a hospital, the 60-year-old commercial property manager was feeling much better, walking and talking without difficulty. After undergoing CT and MRI brain scans as well as numerous blood tests, doctors sent Chesivoir home and advised him to follow up with his internist.
Less than five weeks later, Chesivoir was back in a hospital, his life measured in hours. "He was teetering on the edge," recalled Edward Aulisi, the chairman of neurosurgery at MedStar Washington Hospital Center, who treated him there.
The emergency room doctors had been partly right - but Chesivoir's problem turned out to be every bit as life-threatening as a stroke or a heart attack. And in the intervening weeks two specialists who saw him had missed it.
"You know, you're lucky," Aulisi recalled telling Chesivoir shortly after they met. Without emergency surgery, the neurosurgeon said, patients with his condition "are the people who go to sleep one night and don't wake up."
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A few weeks before the Thanksgiving episode, Chesivoir had suddenly begun experiencing lightheadedness and tingling on his left side. "I felt as if I might not be able to walk or might collapse," he recalled. When an episode occurred in a grocery store parking lot, Chesivoir's first thought was that he was having a stroke. He got back in his car and examined his face in the mirror, unable to detect a facial droop that is a characteristic sign of stroke.
The odd feeling passed quickly and Chesivoir, who had no underlying health problems that could predispose him to a stroke, felt reassured. He'd had similar episodes a few years earlier, but doctors had found nothing. This time his shakiness seemed more pronounced when he stood up after sitting. Chesivoir also began suffering from headaches.
The doctors who reviewed his tests at the emergency room said the only thing of significance was evidence of a possible old brain bleed. Had he fallen or hit his head? Chesivoir told them that he had banged his head on the mantel putting wood in his fireplace and while roughhousing with his teenage sons - but never hard enough to see stars or lose consciousness. "They didn't seem too concerned about it," Chesivoir recalled. Doctors told him they suspected his head pain was caused by either migraines or cluster headaches.
After conferring with his internist, Chesivoir consulted a neurologist. Looking at the images Chesivoir had brought with him from his ER visit, he recalled that she seemed concerned that something on his spine might be causing the tingling. She ordered more tests and scheduled a follow-up appointment for Jan. 21.
But over the next few weeks, Chesivoir's headaches worsened. "I'd go to bed and wake up in the middle of the night feeling like flaming railroad spikes were thrusting into my skull," he said. "But at that point I wasn't too concerned, because so many tests had been done and there was nothing awful found. I figured it was some kind of headache" that could be treated with medication.
On New Year's Eve, while watching a movie at home, Chesivoir stood up, complained that his head hurt and pitched face forward onto a coffee table, briefly losing consciousness. His wife, Carole Klein, called an ambulance; by the time it arrived Chesivoir seemed to be functioning normally. He walked out of the house, met the crew in the driveway and sent them away saying he was okay.
Klein, an intellectual-property lawyer, had grown increasingly worried about her husband. "The scariest thing was that it seemed like his personality was changing," she recalls. "He just wasn't right. Brad is very gregarious and outgoing. He became cautious and would look like he was on edge and afraid."
By Jan. 2, 2014, the headaches were worse. Chesivoir called the neurologist's office and saw a second specialist - the first was out of town - who told him that his problem was most likely an atypical migraine, which is not preceded by the aura many migraine patients describe. "I thought, 'Finally I have a diagnosis,' " Chesivoir recalled. The neurologist prescribed amitriptyline, an antidepressant frequently used to prevent migraines. Chesivoir began taking the drug.
A few days later, he telephoned the new neurologist after developing double vision in his right eye. "We see this with this medication," Chesivoir remembers the doctor saying. "Cut the dose in half."
On Friday, Jan. 11, Chesivoir called the doctor again, minutes after his office opened. His double vision was worse and accompanied by zigzag lines; he was terrified that he was going blind. "I stressed to the doctor's assistant who took the call that this was very serious," said Chesivoir, adding that he was assured that the doctor would call him back. Chesivoir said he never heard from the neurologist.
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On Monday morning Chesivoir called his wife's ophthalmologist, who agreed to see him; she had an opening in her schedule that morning. Klein drove her husband to the office. Minutes after the doctor peered into Chesivoir's dilated eyes, she issued terse instructions to Klein: Drive straight to the emergency room at Washington Hospital Center, where she was on staff. Don't go home first or stop anywhere en route. Chesivoir had papilledema, a badly swollen optic nerve caused by excess pressure on his brain, and needed immediate attention.
When they arrived, Chesivoir said, the ER was a zoo. (The ophthalmologist later told Chesivoir she regretted not calling an ambulance, which would have expedited his admission.) He and Klein were sent to a bay to wait for a doctor. On the other side of the curtain was a family whose members began loudly playing cellphone ring tones. "I lost it and started screaming at them that my head was about to explode and to please keep it down." Chesivoir was admitted several hours later, after undergoing MRI and CT scans. He was told he would be meeting with Aulisi, the neurosurgeon on call.
Aulisi minced no words. Chesivoir had suffered a brain bleed, an acute subdural hematoma, which had grown so large it was now the size of an adult's palm. Without brain surgery, which Aulisi planned to perform first thing the next morning, Chesivoir would probably die. Scans, including those performed on Thanksgiving weekend six weeks earlier, showed evidence of multiple bleeds, some old and some recent. Blood was pressing on brain tissue, causing his visual disturbances, weakness and searing headaches.
A subdural hematoma occurs when blood pools in the space between the dura, which covers the brain, and the surface of the brain. It frequently results from a head injury that can occur during a fall; in some cases the bump is so minor patients don't remember it. In other cases there is no bump at all. Aulisi remembers one patient who developed a serious brain bleed after a violent sneeze.
"It's a closed space, like a pressure cooker," Aulisi said. A buildup of pressure in a confined space can cause the brain to herniate, or shift from its proper position, which is often fatal.
"They basically missed it," said Aulisi of the brain bleeds, adding that diagnosis is easier in retrospect. One reason for the error, he speculated, is that a neurosurgeon did not read the original scans. A radiologist who read Chesivoir's CT scan raised the possibility of old bleeds, but other doctors did not pursue that.
By the time Aulisi saw Chesivoir, there was no choice other than surgery. Klein said he told the couple that Chesivoir probably had less than 24 hours to live when he reached the ER.
"I just sort of felt like I was waiting for the inevitable," Chesivoir recalls of the night before his operation. Klein remembers feeling terrified and trying to calm their children, who were then 16 and 20.
The surgery went well. In the recovery room, Chesivoir said, he "felt so much better that I hadn't realized how bad I had felt." Recovery was arduous and involved lying flat on his back for two days. At one point Chesivoir suddenly became confused, triggering fears that he might have suffered cognitive damage, a known complication of the surgery, or another bleed. But the confusion resolved within hours and was chalked up to postoperative swelling.
"That was the scariest part of the whole episode," Chesivoir said. "I wasn't that afraid of dying, but I didn't want to be a burden on my family."
Several weeks after he was sent home, Chesivoir, whose hobbies include photography, was taking pictures again, his vision dramatically improved. After three months he had fully recovered.
The ordeal was life-changing, he said. "When things bother me now I just have to remind myself that in the continuum of problems, this is very small."
Klein said that her husband's experience has shaken her faith in doctors. In retrospect, she said, she's not sure what else they could have done. "There was nothing different to do," she said. "We had gone to an ER and seen two neurologists. I felt like we covered the bases. There were so many misses."
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