Acute Neurology Expert Witness and Neurohospitalist Review

Neurologic patients often present to the hospital before the diagnosis is clear. Symptoms may evolve over minutes, hours, or days, and early decisions are frequently made with an incomplete history or an examination that changes over time.

Although stroke is an important consideration in many acute neurologic presentations, the differential diagnosis is often much broader.

Dr. Cheung reviews the history, neurologic examination, imaging, laboratory data, treatment response, consultations, and subsequent clinical course together. The goal is to understand what information was available as the case evolved and what diagnoses and treatment options were reasonably being considered at each stage.

A later diagnosis may help explain what happened, but it does not automatically establish what should have been apparent earlier.

Seizures can present clearly, but they can also be intermittent, subtle, or difficult to distinguish from other causes of abnormal movements or altered mental status.

Medical-legal review may involve recognition of recurrent or ongoing seizure activity, changes in the neurologic examination, diagnostic evaluation, treatment response, neurologic consultation, and escalation of care.

In status epilepticus, the clinical course and timing of treatment can become particularly important. Dr. Cheung reviews those events in sequence and considers whether an alleged delay or treatment decision materially affected the subsequent neurologic course.

Hypoxic-ischemic encephalopathy involves neurologic injury following a period of inadequate oxygen delivery to the brain.

The eventual neurologic outcome may reflect the severity and duration of the underlying hypoxic event, the patient's baseline condition, subsequent medical complications, and the evolution of brain injury over time.

Review may include the circumstances of the initial event, serial neurologic examinations, neuroimaging, other neurologic testing when relevant, and the subsequent hospital course.

As with other acute neurologic injuries, the timing and extent of the underlying injury have to be separated from later events when evaluating causation.

Acute spinal cord disease may present with weakness, sensory changes, pain, gait dysfunction, bowel or bladder symptoms, or a combination of findings that evolve over time.

Cases may involve whether the neurologic presentation was reasonably recognized, whether appropriate imaging or consultation was obtained, whether escalation or transfer was indicated, and whether an alleged delay changed the degree of neurologic injury.

The analysis depends on the clinical presentation, localization of the neurologic findings, imaging, treatment opportunities, and the course of the underlying spinal cord process.

Meningitis, encephalitis, and other central nervous system infections can present with altered mental status, seizures, headache, fever, focal neurologic findings, or less specific symptoms.

The diagnosis may not be obvious at the beginning of the hospital course.

Medical-legal review may involve the evolving clinical presentation, differential diagnosis, diagnostic testing, neurologic consultation, treatment decisions, and whether subsequent deterioration changed what should reasonably have been recognized.

The relevant question is not simply whether an infection was eventually diagnosed, but what information was available and what actions were reasonable as the presentation developed.

A patient may deteriorate neurologically after hospital admission even when the reason for that deterioration is not immediately clear.

New focal deficits, worsening mental status, seizures, progression of an existing neurologic injury, medication effects, systemic illness, or a new neurologic process may all need to be considered depending on the clinical circumstances.

Dr. Cheung reviews changes in the neurologic examination together with the timing of imaging, diagnostic testing, treatment, consultation, escalation of care, and the subsequent clinical course.

The sequence matters because a later explanation for deterioration does not necessarily establish when that explanation should first have been apparent.

Hospital-based neurologic review often depends on reconstructing what happened over time.

Dr. Cheung reviews relevant CT, CT angiography, CT perfusion, and MRI studies in the context of the medical record and neurologic examination. Imaging may clarify structural injury, vascular findings, progression of disease, or possible explanations for neurologic deterioration.

The imaging is not treated as a separate exercise from the clinical review. It is considered together with the patient's symptoms, examination, treatment decisions, and subsequent course.

This becomes particularly important when the medical-legal question involves whether an injury was already established, whether a condition was evolving, or whether an alleged delay materially affected the outcome.

Standard of Care and Neurologic Causation →

Depending on the facts of the matter, acute neurology review may address questions such as:

• Was the neurologic condition reasonably recognizable at the time?
• Was the differential diagnosis appropriate for the presentation?
• Were changes in the neurologic examination appropriately evaluated?
• Was additional imaging, testing, consultation, treatment, or transfer reasonably indicated?
• Was neurologic deterioration recognized and addressed?
• Did an alleged delay change a treatment opportunity?
• Was neurologic injury already established before the alleged deviation?
• Does the imaging support the proposed sequence of events?
• Would different care likely have changed the degree of neurologic injury or disability?
• Where does the available medical record leave meaningful uncertainty?

The specific questions depend on the clinical record and the neurologic condition involved.

Through Crux Neurology, Dr. Cheung provides:

• Early case screening and consultation
• Medical record review
• Clinical timeline reconstruction
• Neuroimaging review
• Standard-of-care review
• Neurologic causation analysis
• Review of opposing expert opinions
• Written expert opinions and reports
• Deposition testimony
• Trial testimony

Dr. Cheung accepts matters that fall within his current clinical practice and areas of expertise.

Dr. Cheung is board-certified in Neurology and Vascular Neurology and practices as a neurohospitalist caring for patients with acute stroke and other hospital-based neurologic emergencies.

He serves as Stroke Medical Director at a Comprehensive Stroke Center and has more than six years of independent clinical practice.

His clinical work requires assessment of evolving neurologic symptoms, time-sensitive treatment decisions, neuroimaging, changes in neurologic examination, and escalation of care in the hospital setting.

Learn more about Ryan Cheung, DO →

Attorneys, insurers, and other professional organizations may contact Crux Neurology regarding a potential acute neurology matter.

Every inquiry is reviewed. CV and fee schedule materials will be sent following review.

Please do not submit protected health information, patient names, medical records, or other confidential case information through the initial inquiry form.