Stroke Misdiagnosis in
the Emergency Room
Sean Domnick and Nicole Kruegel
Domnick Cunningham & Whalen
Palm Beach Garden, FL
Stroke cases are some of the most complicated and expensive cases to pursue, but they often begin with a similar story: A loved one started acting strangely. 911 is called and they are taken to an emergency room. The emergency room doctor decides, without doing a full workup, that nothing is wrong, and leaves the patient alone in a room for hours. Then, hours or days later, it is discovered that the patient had actually had a stroke, but because of the delay in diagnosis, no treatment is possible to reverse its effects.
There is a maxim when it comes to stroke: Time is brain. As a result, medicine has evolved in two very important ways. First, the recognition that systems be in place at Hospitals to identify stroke as rapidly as possible. Second, the development of treatments that can reverse or stem the devastating effects of stroke. One does not work without the other.
There are two types of strokes: hemorrhagic and ischemic. A hemorrhagic stroke occurs when there is bleeding in the brain. An ischemic stroke occurs when a clot breaks off from somewhere else in the body and travels to the brain – cutting off blood supply and oxygen to parts of the brain. Ischemic strokes have a broader range of treatment options that can drastically improve the patient outcome if proper measures are taken. In cases of medical malpractice, the delayed diagnosis of an ischemic stroke can have tragic outcomes including brain damage and death.
In the United States, over 1,100 hospitals have been certified as stroke centers by the Joint Commission, yet, time and again, physicians working in the emergency rooms at these hospitals fail to properly evaluate stroke patients, causing life-altering delays that close the door on any opportunity for meaningful recovery after a stroke.
In the past, the only treatment available for an acute ischemic stroke was the “clot buster” known as tPA (tissue plasminogen activator). With timely identification and treatment of an ischemic stroke, administration of tPA resulted in a better functional outcome in only about a third of patients. More importantly, however, tPA must be administered within 4.5 hours from the first onset of stroke symptoms (“last known well time”).
THE MISSED WINDOW
Beginning in 2014, the results of several clinical trials were published which showed a marked improvement in outcome for patients who underwent a thrombectomy to remove the clot following an ischemic stroke. These studies led to a change in the standard of care from requiring the administration of tPA within 4.5 hours of last known well time, to the performance of a thrombectomy within 6 hours of last known well time. Since 2015, the window for treatment of some ischemic strokes with thrombectomy has been extended to 24 hours from last known well time. This is a complete paradigm shift in the thinking about stroke treatment. In the past, many patients who were not able to provide a last known well time within the 4.5 or 6-hour window did not receive treatment for their stroke, despite the very strong likelihood that such treatment would have improved their outcome. Often, these “missed window” patients were the result of physicians failing to make any effort at determining the last known well time, then deciding not to change course once they had realized their mistake.
There are two types of stroke certifications available to hospitals under the Joint Commission: primary and comprehensive. Primary stroke centers are capable of administering tPA to patients suffering an acute ischemic stroke. Comprehensive stroke centers are capable of administering tPA as well as performing thrombectomy. With shift from tPA to thrombectomy as the preferred treatment for stroke, this is a critical distinction that many hospitals fail to disclose when they advertise their stroke capabilities to the public, and even when a patient who would benefit from a thrombectomy is identified at a primary stroke center, they are often not transferred to a comprehensive stroke center.
MISSED OR MISDIAGNOSIS
Despite working in certified stroke centers, many emergency room physicians do not know how to perform a complete stroke evaluation. Often, patients who have suffered a stroke are mistaken for drug overdoses and, rather than performing a full evaluation, are left in a corner to “sleep it off.” Because “time is brain,” stroke should be on the differential diagnosis for every patient that comes into the emergency room with an altered mental status and should be ruled in or out as soon as possible. Waiting to see if a patient “sleeps it off” before performing a full stroke assessment can lead to devastating brain damage or even death.
The first, and perhaps easiest assessment, is an NIH Stroke Scale Assessment, which can be done in only a few minutes and does not require any special equipment. A competent physician should be able to identify the majority of strokes this way.
The next step is to obtain a CT of the brain. This test is necessary for two reasons: 1) helping to determine whether the patient has suffered an ischemic or hemorrhagic stroke, and 2) evaluating the timing of the stroke. A negative CT scan, however, does not mean that the patient is not having a stroke. Perhaps the most common mistake I see from emergency room physicians is where, for a patient who is exhibiting signs of a stroke but has a negative CT scan, the physician stops their evaluation and decides that there is no stroke. A CT scan will only show an ischemic stroke several hours after it has occurred. A CT scan will not show a stroke that has recently occurred and that is within the best window for treatment. Therefore, the next step after a CT is to get a CTA, which is a CT with contrast. This test is necessary for both patients where an ischemic stroke was identified on the regular CT as well as for patients with a negative CT. A CTA can be performed immediately after the CT scan, and is crucial in identifying the existence, size, and location of clots. Once the clot is identified, an interventional neuroradiologist needs to be consulted on whether a thrombectomy can be performed.
Delayed or missed diagnosis of a stroke can have a life altering impact on a patient. Often, hospitals advertise as stroke centers yet fail to follow the standard of care when evaluating a patient for a stroke. Understanding the medicine is critical for doctors, and for the lawyers who hold them accountable when tragedies occur.