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WV Hospital Admits CT Brain Scan Overdoses

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An undetermined number of patients at a West Virginia hospital suffered radiation overdoses as recently as late November, nearly a year after a national Food and Drug Administration warning that was prompted by hundreds of similar overdoses at other hospitals.

The patients—suspected stroke victims—received CT brain perfusion scans at Cabell Huntington Hospital in Huntington, West Virginia.

The hospital has known of at least some of the overdoses since December and has sent letters to several patients, according to a New York Times story published Saturday. The Times said the hospital did not otherwise disclose the overdoses publicly until the Times called the hospital for comment late last week.

At that point, the hospital issued a news release saying that some patients (the hospital declined to say how many) receiving CT scans during the period from October 2009 through November 2010 may have received exposure to radiation above the recommended level.

In December 2009, the FDA notified hospitals and other medical facilities across the country about recommendations to lessen the possibility of radiation overdoses during CT brain perfusion scans. The FDA had learned of more than 200 cases of overexposure in California and elsewhere.

Did the radiology department at Cabell Huntington not get the memo? The hospital isn’t saying; it declined to explain why or how the overdoses occurred. According to local media outlets, such as WSAZ-TV in Huntington, the news release did say :

[While] these patients may have received a dose higher than recommended, it was still within the range of normal for complex imaging procedures.

An expert consulted by the New York Times disputes that. Rebecca Smith-Bindman, MD, a radiology professor at the University of California, San Francisco, who has testified before Congress advocating more controls over CT scans, called the dosage report for one Huntington patient “grossly and unacceptably abnormal.”

A Los Angeles lawyer told the Times he and his associates represent at least 20 Cabell Huntington patients who received letters saying they had received too much radiation.

One of them is Marcie Iseli, 36, who lost hair in a band around her head that matched the path of the CT scan. She received her scan on November 16 after experiencing nerve weakness on one side of her face. Her records indicate that she received at least 10 times too much radiation, said Dr. Smith-Bindman.

The Times said FDA records show that GE Medical Systems, which made the CT scanner, filed a report in December regarding a CT radiation dose at the hospital in June 2010 that was 5.6 times higher than GE’s guidelines. GE said a hospital technician had “manually adjusted” the radiation output to obtain a clearer picture, though greater clarity was not needed for diagnosis. It said technicians had subsequently received “refresher training.”

GE also filed a second report in January 2011 about a similar episode that occurred in March 2010.

Perhaps additional “refresher training” may be in order.

Related seminar: Neuro & Musculoskeletal Imaging

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One Response to “WV Hospital Admits CT Brain Scan Overdoses”

  1. Radiology Daily»AlertArchive » CT Brain Scan Lawsuit Stands Poised In WV on March 25th, 2011 at 10:03 am

    […] we reported early this month, Cabell Huntington Hospital in Huntington issued a press release saying that some patients […]