Neurologist’s Workup of Stroke Patient Contributes to Cerebral Death

This case involves a seventy-seven-year-old woman with a medical history of hypertension, hyperlipidemia, and infrequent palpitations who presented to the hospital with an acute onset of slurred speech. The patient arrived outside of the window period for the administration of tPA and doctors advised that no other medical intervention was indicated other than supportive care. Subsequently, the patient was admitted to the stroke unit for further observation but at no time was an EKG, neuroradiology, or any other cardiac testing performed to rule out an embolism as the cause of the stroke. Three days into her hospital stay, the patient again displayed significant signs of stroke and was no longer able to support her own airway. She was placed on a ventilator and further brain imaging showed extensive cerebral damage consistent with brain death. The patient’s family elected to remove her from the respirator and she died shortly thereafter.

Question(s) For Expert Witness

1. What additional tests could have been performed to alter this patient's outcome?

Expert Witness Response E-000197

This patient had a history of palpitations. Although infrequent, her palpitations should have raised the suspicion of a possible arrhythmia as a cause of her stroke. Because paroxysmal atrial fibrillation (PAF) episodes are often subclinical, ambulatory ECG monitoring was a reasonable additional evaluation in this patient and may have helped to prevent the fatal embolism.