inforMED
DeathORR

CLEARPOINT

Received Sep 18, 2017 · Event occurred Apr 14, 2017

Report 1125732-2017-00003 · MDR key 6873544

Device

Generic name

Neurological Stereotactic Instrument

Model number

N/A

Catalog number

N/A

Lot number

N/A

Product problems

  • Adverse Event Without Identified Device or Use Problem
  • Adverse Event Without Identified Device or Use Problem

Patient

14 YR

  • Death
  • Death

Narrative

Additional Manufacturer Narrative

SURGEON BELIEVES THE EVENT WAS DUE TO THE CLEARPOINT/VISUALASE PROCEDURE INITIATING THESE CASCADING EVENTS, BUT ON REVIEW OF THE CASE COULD NOT DETERMINE A SPECIFIC CAUSE. DEVICE NOT RETURNED.

Description of Event or Problem

PTX HAD A PREVIOUS BIOPSY APPROXIMATELY 1 MONTH PRIOR TO THIS PROCEDURE CONFIRMING A GLIOMA. A CLEARPOINT/VISUALASE PROCEDURE WAS PERFORMED ON (B)(6). DURING THE PROCEDURE ALL INDICATIONS WERE NORMAL, WITH THE STYLET AND VISUALASE PROBE AT THE INTENDED TARGET. WITHIN 6-8 HOURS FOLLOWING COMPLETION THE PTX BEGAN TO DETERIORATE. EXAMINATION DETERMINED THE PTX HAD A SUBARACHNOID HEMORRHAGE. A DRAIN WAS PLACED TO RELIEVE PRESSURE. APPROXIMATELY 1-2 DAYS AFTER THE PTX EXPERIENCED A CEREBRUM STROKE AND SURGICAL DECOMPRESSION WAS PERFORMED, BUT THE PTX CONTINUED TO SUFFER PROGRESSING AND EVOLVING ISCHEMIA AND STROKE TO OTHER PARTS OF THE BRAIN. THE PATIENT DIED 4 DAYS AFTER THE PROCEDURE FROM PROGRESSING AND EVOLVING ISCHEMIA AND STROKE.