Delay in Ischemic Stroke Treatment Leads to Permanent Cognitive Disabilities

This case involves an elderly female patient who developed numbness on her left side and went immediately to her local hospital. Imaging showed possible stroke and swelling. She was not given tPA and was urgently transferred to another medical center. More imaging confirmed stroke showing both ischemic and hemorrhagic components. The patient was told she would be seen emergently as soon as the stroke team arrived at the hospital. However, she was not seen for over 12 hours, during which time her condition worsened, and another MRI was taken which showed worsening ischemic stroke. The patient suffered complications including brain swelling. She continued to have a significant decline in her cognitive abilities.

Question(s) For Expert Witness

1. Do you routinely see this type of patient?

2. What type of effect can a delay in intervention have on the cognitive function of a patient with this type of presentation?

Expert Witness Response E-041967

Patients with stroke are not all eligible for tPA, but if they are, then tPA can lead to increased likelihood of functional improvement. Patients with stroke may also be candidates for clot retrieval if they present in an appropriate window of time and meet criteria for endovascular therapy. "Time is brain," so the faster patients get to the hospital, the faster they can get tPA or clot retrieval. Delay in either intervention may lead to worsening functional status and lower likelihood of recovery. I am curious to know how much time elapsed from the onset of the patient's symptoms to the time she presented to the hospital. An ischemic stroke should not be visible on a CT immediately. Furthermore, there should not be swelling seen on a CT from an ischemic stroke immediately, and there should only ever be swelling from an ischemic stroke if it is large. If, however, she had a bleed, then one could expect to see some swelling. If she had a bleed, though, she certainly would not have been a tPA candidate and it is reasonable that she did not get tPA at that time. Additionally, if an ischemic stroke was seen on the CT, this could also represent a reason to withhold tPA, but it would depend on what the stroke looked like and how much time had passed since symptom onset and whether or not there were any other criteria that made her ineligible for tPA. Once the MRI showed ischemic and hemorrhagic stroke, she was clearly not a tPA candidate anymore.