A 58 y.o. man woke up on July 7, 2022 around 7:30 AM and when he got up, he felt very unstable, dizzy (almost foggy), lightheaded and unbalanced. Wife took him to his PCP around 9 AM, and they claim that he was very unsteady and couldn’t walk alone.
Chief Complaints: “dizziness”; “c/o episodes of dizziness”; rash in left arm, itchy and skin discoloration.
HPI: presents w/ symptoms of dizziness, denies any vertigo, and everything else is normal, including no headache or visual disturbance…
ROS: everything appears normal; ….no tremor; (+) difficulty walking.
PMH: hyperlipemia and hypertension; overweight (235 lbs 5’9”); EKG hx: T wave abnormal onset 2/2021.
The measured BP was 170/96. The Doctor performed a physical exam, which included some neurological tests: checked his grip strength and finger to nose exam; checked eyes and throat.
A/P: symptoms of dizziness, symptoms started this AM; no associated symptoms or SOB or chest pain, clinical exam and neuro exam WNL other than skin dry. Recommend to rest, increase fluid intake, and avoid strenuous activity. Dizziness and giddiness (unbalanced and lightheaded).
BP was initially elevated, however, returned to normal post exam, recommended to continue walking and exercise; continue Toprol XL
Told to RTO as needed. This appointment is documented as occurring at 10:20 am
According to the family, he was examined and diagnosed as being dehydrated and advised to drink fluids.
The physician informed the patient “not to think the worst”, and assured him that “he was fine”; don’t think that this is a stroke.
Patient asked for a doctor’s note b/c he was supposed to go to work later in the day, and he knew that he physically could not do so.
Following the appointment, patient and spouse went to Whole Foods to buy hydrating water and drank one bottle but symptoms failed to subside, and in fact, began to worsen with c/o double vision. The wife noted that his eyes were off track and not aligned normally and she transported via car to Medical Center at around 3 pm. During this time, wife also messaged doctor through their messaging system and received a call from the nurse that he was gone for the day.
Once at Hospital, which is a stroke center, moved quickly with CT scan and diagnosed infarction.
CT head/brain.
1. No evidence of intracranial hemorrhage, mass effect or large acute infarct
2. There is a chronic lacunar infarction in the head of the left caudate nucleus
3. If there is clinical concern for an acute infarct and symptoms persist or worsen, consider f/up with MRI of the brain for more detailed evaluation.
CT Angio Head:
1. Occluded intracranial left vertebral artery. Patent right intracranial vertebral artery.
2. No intracranial large vessel occlusion within the anterior circulation
CT Angio Neck:
1. Occluded entire left vertebral artery
2. Within the remaining major cervical arterial vasculature, no high grade/critical stenosis or occlusion
MRI:
Subcentimeter posterior pontine acute to subacute infarct. Partially imaged nonvisualization of a patent left vertebral artery flow void in patient with known occlusion. Subcentimeter anterior right frontal high diffusion favored to be artifactual or subacute to chronic.
The patient was advised that small veins in the back of the brain were affected. He was placed on blood thinners.
He was discharged July 10th due to insurance reasons to follow up with neurology, PT and OT.
He suffered the following deficits: loss of employment, unable to see in both eyes, right side of face and body seem to have been affected; he cannot move independently.
Questions:
1. Was there a delay in diagnosis?
2. Was an intervention (e.g. thrombectomy) indicated in this case, or was treatment with blood thinners only appropriate?
3. Did a delay in diagnosis result in loss of opportunity for intervention (e.g. thrombectomy)?
4. Would an earlier diagnosis have resulted in improved outcomes?
Files:
No questions yet!
Do you believe there might have been medical error?
Acute inability/difficulty to ambulate is an emergency and the differential diagnosis of acute stroke should be entertained with these types of complaints. The impression that neurological examination was normal is not accurate - gait is a component of neurological examination and inability/difficulty walking is technically an abnormal examination.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
While the diagnosis of stroke was technically delayed by several hours, it is almost certain that acute infarct was already present upon awakening since the symptoms were already present upon awakening. It will be very hard if not impossible to establish definitively whether the symptoms of double vision would have developed had the diagnosis been established a few hours earlier (or not),Acute infarcts can fluctuate and/or worsen despite treatment, particularly small territories in the pons and/or basal ganglia. Based on the history, this is a wake-up stroke, which typically means that the time of onset of stroke is usually established by using the last known well time (usually bedtime) as a surrogate time. In terms of establishing whether the delay in diagnosis clearly caused injury, we don't have the information as to whether this patient was in the thrombolytic treatment timeframe (4.5 hours of symptom onset) at the time of initial presentation to the PCP at 9 AM because we do not have a clear last known well time or time of symptom onset. Nowadays, wake up strokes where patients have gone to bed normal can be triaged for thrombolytic treatment eligibility by a rapid brain MRI. The MRI can effectively time the infarct as occurring within 4.5 hours or not. However, please note this is not always available at all US hospitals. Therefore in my opinion the only way to clearly establish causality between diagnosis delay and injury would be for all of the following to be true: (a) the patient was within the thrombolytic treatment window (by history) OR (b) the patient went to an ED that realistically could have triaged the patient with a emergent brain MRI AND that brain MRI suggested that the LKW time was within 4.5 hours AND (c) the patient could have ostensibly received thrombolytic treatment within the approved/accepted time window If either (a) or (b) are true in this case, then according to much of the literature the standard of care would have been to treat the patient with thrombolytic and sooner diagnosis and treatment with thrombolytic would have theoretically improved the chance of functional independence at 90 days (which is the clear signal that has been demonstrated in high quality trial data). Most importantly, it is not clear whether (a) or (b) are true or false given the information above. (c) is likely to be true since the ED where the patient presented was a Stroke Center. RE: thrombectomy - on the facts of this case alone as presented above, the patient's case would not have been referred for thrombectomy as long as the vertebral artery only was occluded. These lesions are typically not intervened upon with endovascular thrombectomy unless the basilar (which is just distal to the end of the vertebral arteries) is clearly occluded and causing acute stroke symptoms. The basilar does not appear occluded here.
What makes you a good expert for this case?
I am a board-certified vascular neurologist and actively practice evaluating and managing stroke inpatients at a large academic medical center. I staff acute stroke presentations routinely every time I am on service (total of ~ 2 calendar months of time per year; note this is not consecutive and can be scheduled 1-2 week blocks at a time). I also teach residents, fellows, and medical student trainees in vascular neurology.
How often do you encounter cases similar to this one in your practice?
I manage and evaluate wake-up strokes in up to 25-33% of our acute stroke cases managed in my practice
Do you believe there might have been medical error?
The assessment that dehydration was the diagnosis for the severe dizziness was likely off from the very start of physician evaluation. In a patient with risk factors for stroke, as in this case, an ischemic stroke should be considered in the differential diagnosis especially if sudden in onset. Patient could have been administered hydration while in office and reassessed. On the other hand, neurological exam was reported as intact which would not be the case if there was an ischemic stroke in a large area of the brain.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Precautionary recommendation to get an assessment in an emergency room would have potentially avoided long term effects.
What makes you a good expert for this case?
I have over 20 years of clinical experience and have cared for hundreds of patients with ischemic strokes especially in an ICU setting.
How often do you encounter cases similar to this one in your practice?
As above, while in clinical practice ny job was to care for patients with acute neurological deficits especially stroke.
Do you believe there might have been medical error?
Given that he woke up with the symptoms it would depend when he fell asleep or was last “normal”,” however most likely he presented out of the window (4.5 hours) for thrombolytics. In terms of thrombectomy, his symptoms in the morning were mild with a low NIH stroke scale (less than 6) and localize to the posterior circulation, all of which point away from being a thrombectomy candidate. Thrombectomy is well studied in the anterior circulation and is generally reserved for “Hail Mary” posterior circulation cases The symptoms worsened in the afternoon and he was promptly seen in the ED. The MRI report appears to reflect a small size stroke which would not fit with an acute left vertebral occlusion. Also the report hedges on acute vs subacute (which is generally regarded as 10-15 days old) so it appears the stroke was not hyper acute (within hours). Most likely he had with severe stenosis or occlusion already and just became symptomatic at one point.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The delay in stroke diagnosis would not have changed clinical management in most clinical scenarios as described in the previous answer.
What makes you a good expert for this case?
I am a triple board certified neurologist, stroke and neuro ICU specialist with a decade of clinical experience. I currently am a full time inpatient stroke physician.
How often do you encounter cases similar to this one in your practice?
1-2 a week (posterior circulation stroke with fluctuating symptoms)
Do you believe there might have been medical error?
This is a wake up stroke. He was neither a candidate for tPA nor thrombectomy. His only option anti platelet therapy which more likely than not was not going to change his outcome. Moreover, his symptoms while in retrospect were due to a stroke, were non-specific and are frequently due to a a peripheral problem (inner ear).
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This is a wake up stroke. He was neither a candidate for tPA nor thrombectomy. His only option anti platelet therapy which more likely than not was not going to change his outcome. Moreover, his symptoms while in retrospect were due to a stroke, were non-specific and are frequently due to a a peripheral problem (inner ear).
What makes you a good expert for this case?
I am a neurologist at a tertiary care academic medical center. I have authored over 100 peer reviewed articles on stroke. I have served as an expert on over 100 cases, both for the defense and plaintiff.
How often do you encounter cases similar to this one in your practice?
Many times. This is a typical case of a posterior fossa stroke. I have seen cases like this many times.
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