Suspected Stroke Patient Receives Delayed Artery Dissection Treatment

This case involves an overweight diabetic female patient who presented to the emergency room with aphasia and limited range of mobility. After being admitted, she was unable to move her extremities. The emergency room physician called a stroke code and a head CT was performed which came back negative. A neurologist was then consulted and she ordered an MRI which also came back negative. The stroke code was then called off due to the negative imaging studies. The patient was kept in the hospital for further monitoring and complained of head and neck pain. Several days later, it was determined that the imaging had been read incorrectly by the radiologist. A neuroradiologist re-read the images and the patient was diagnosed with vertebral artery dissection.

Question(s) For Expert Witness

1. Do you have experience treating patients with stroke?

2. How important is having correct imaging studies when diagnosing and managing a stroke?

3. Had this patient's imaging studies been read correctly, would the ED physician's management have changed? Please explain.

Expert Witness Response E-006248

I have 15+ years of experience working in an academic, urban emergency department setting where stroke presentations are common. I see multiple patients with stroke symptoms per shift and I diagnose and treat patients with all varieties of hemorrhagic and ischemic strokes, including those like the patient in this current case whose primary cause is likely dissection. I have lectured on the subject of stroke management to our medical students and emergency medicine residents. My initial thought is that the delay in diagnosis based on radiology had a significant impact on the patient's treatment. Depending on the exact timing of the presentation and other factors, the delay in diagnosis may have significantly impacted the patient's outcome. For the emergency physician caring for a stroke patient, correct imaging study reads are critical. When a stroke code is called, the CT scanner is cleared so that an initial head CT can be done. The purpose of this is to look for contraindications (such as bleeding) to giving medicine that will break up blood clots or doing an endovascular procedure to remove the clot. Time is of the essence with these treatments and every minute can lead to a worse outcome. Without the correct radiologic diagnosis, the correct acute and subacute treatments cannot be made. If the scans had been correctly read, depending on the timing and other factors, many different possible treatments may have occurred including: transfer to a stroke center if the patient was not already at one, giving medicines to break up clots, using endovascular techniques to remove clot, and/or starting anti-platelet or anti-coagulation drugs. Each of these may well have altered the patient's outcome.