Delay in Stroke Intervention Results in Patient’s Permanent Disability

Case Summary

An ambulance brought a middle-aged male with a history of chronic pain and meloxicam and tramadol treatment to the emergency room. The patient’s spouse reported waking to find her husband crawling from the bedroom to the bathroom. He told her he thought he was about to vomit when suddenly he collapsed to his side. His eyes then rolled upward. His arms and legs became rigid. He began shaking and was non-responsive. Minutes later, emergency medical services arrived. They intubated the patient to protect the airway and administered lorazepam and midazolam.

Within 30 minutes, an emergency department physician evaluated the patient. The physician read a CT angiogram of the head and neck as negative for acute pathology. The radiologist noted a 2 mm bulge of the intracranial portion of the vertebral artery on the right at the region of the posterior inferior cerebellar artery origin, possibly representing an infundibulum or small saccular aneurysm. The radiologist then noted that a subsequent exam could follow this finding.

The patient’s bloodwork showed lactic acidosis and acute kidney injury. He went to the intensive care unit for the management of seizures and acute encephalopathy. Upon his admission, his care team noted that he had pupils 6 mm and an absent corneal reflex. He had abnormal spontaneous flexion in bilateral upper extremities and left great toe. Additionally, the patient was not responsive to verbal or noxious stimuli. His care team requested a neurology consultation.

However, the consulting neurologist didn’t evaluate the patient until the following day. An MRI revealed extensive acute ischemia of the left thalamus, occipital lobe, bilateral brainstem, and cerebellum.

Case Theory

Basilar artery occlusions (BAOs) are an infrequent subset of posterior circulation strokes that invariably leads to death or long-term disability if not treated emergently. Delay in the diagnosis of stroke is a well-known cause of high morbidity and mortality. As such, emergency responders and emergency room staff know the importance of identifying and treating strokes. Most commonly, patients experiencing basilar artery occlusion exhibit acute neurologic signs including motor deficits, hemiparesis or quadriparesis, and facial palsies. In addition, they experience dizziness, headache, and speech abnormalities—especially dysarthria and difficulty articulating words.

Patients can experience near-complete recovery if treatment is provided promptly. However, the time from the onset of symptoms to diagnosis in the emergency department is often significantly delayed in BAO. Doctors who see and treat stroke patients know that “time = brain.” The sooner the doctor initiates treatment, the more likely they can preserve brain function. The longer treatment is delayed, the more chance of significant deficits and the increased likelihood of permanent disability. For this reason, the 60 minutes after the onset of stroke symptoms are known as “the Golden Hour.” When treatment is initiated within this brief window, the patient’s prognosis and recovery are improved.

In this case, the patient became severely disabled due to failure to timely observe and treat basilar artery occlusion.

Expert Witness Specialities

Emergency Medicine

An expert in ER medicine can review the patient’s medical records, opine on the missed Golden Hour opportunity, and identify the errors that led to the delay in correct treatment.

Critical Care Medicine

An expert in critical care medicine can review the patient’s medical records and opine on the care received upon admission.

Radiologist

An expert in radiology can review the patient’s medical records for violation of the standard of care and can opine on the image read and follow up.

Questions for Expert Witnesses

• How does the timeliness of intervention typically affect outcomes in patients who present with seizures and subsequently received a stroke diagnosis?
• What significance did the radiology report play in the misdiagnosis of this patient?
• When primary treatment teams order specialty consultations in the intensive care unit or medical floor, what is the team’s responsibility to ensure that the consultations happen in a timely manner?

Expert Witness Involvement

Here is what the neurology expert in this case had to say:

Expert Witness Response E-036010

I am a Professor of Neurology and Neurocritical Care and a full-time neurointensivist. I treat patients in our Neuroscience ICU on a full-time basis as an attending neurointensivist. Immediate and ongoing seizure control is paramount for the management of patients with acute stroke. This patient may have benefited from continuous EEG monitoring, as patients having a generalized seizure in the setting of stroke are at risk for subclinical status epilepticus, which is treatable with anti-epileptic medications and sometimes anesthetic agents such as propofol or midazolam IV infusions. The patient's unresponsiveness could have been due to ongoing seizures. At our academic institution, our Neurology team sees an urgent or emergent neurological condition within 15 minutes. If the consulting physician is outside the hospital, they are to be available within 30 minutes. Less urgent conditions may be seen on the same day, depending on the case.