Stroke misdiagnosis is a major healthcare concern with initial misdiagnosis estimated to occur in 9% of all stroke patients in the emergency setting according to the authors of a 2018 paper entitled Diagnostic Error in Stroke-Reasons and Proposed Solutions published by Current Atherosclerosis Reports.

The misdiagnosis of a stroke may result in significant harm to patients as a result of a failure to initiate timely treatment and/or secondary prevention strategies.

Young patients, women, minorities, and patients presenting with non-specific, transient, or posterior circulation stroke symptoms are at increased risk of misdiagnosis.

WHAT IS A STROKE?

The Canadian Heart & Stroke Foundation website explains that a stroke occurs when blood stops flowing to any part of the brain which in turn causes damage to brain cells. The effects of a stroke depend on the part of the brain that was damaged and the amount of damage done. 

Broadly speaking, there are four classifications of stroke:

• Ischemic stroke. An ischemic stroke is caused by a blockage or clot in a blood vessel in the brain. The blockage can be caused when a substance called plaque builds up on the inside wall of an artery. The blockage or clot grows as blood cells and fat cells stick to the plaque. Gradually, it grows big enough to block normal blood flow. The blockage or clot can form in an artery in the brain. It could also form in an artery in another part of the body and travel to the brain.

• Transient ischemic attack (TIA). A transient ischemic attack (TIA) is caused by a small clot that briefly blocks an artery. TIA and minor ischemic stroke fall along a continuum. TIA symptoms disappear completely within 24 hours (usually within one hour). If any symptoms still exist after 24 hours, then it would be considered a stroke, not a TIA. A TIA can be a warning of a future stroke. 
• Hemorrhagic stroke. A hemorrhagic stroke is caused when an artery in the brain breaks open. The interrupted blood flow can cause brain cells to die leading to injury to the brain. High blood pressure makes arteries weak over time and is a major cause of hemorrhagic stroke. Weak spots in the arteries called aneurysms can stretch too far and eventually burst.

• Other causes: In rare cases, an underlying condition such as a tumour, an infection, or brain swelling due to an injury or illness can cause a stroke. Some people have irregularities in their arteries at birth that can cause a stroke later in life.

WHAT ARE THE SIGNS AND SYMPTOMS OF STROKE?

According to the Mayo Clinic, signs and symptoms of stroke include:

• Trouble speaking and understanding what others are saying. A person may experience confusion, slur words or have difficulty understanding speech.
• Paralysis or numbness of the face, arm or leg. A person may develop sudden numbness, weakness or paralysis in the face, arm or leg. This often affects just one side of the body. If a person tries to to raise both their arms their your head at the same time and one arm begins to fall, they may be having a stroke. Also, one side of their mouth may droop when they try to smile.
• Problems seeing in one or both eyes. A person may suddenly have blurred or blackened vision in one or both eyes, or they may see double.
• Headache. A sudden, severe headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate that a person is having a stroke.
• Trouble walking. A person may stumble or lose their balance. They may also have sudden dizziness or a loss of coordination.

HOW ARE STROKES DIAGNOSED?

A physician will need to perform a number of tests in order to diagnose a stroke which may include the following:

• A physical exam. A physician will do a number of physical tests including listening to the patient’s heart and checking blood pressure. A neurological examination will also be performed to see how a potential stroke is affecting the nervous system.
• Blood tests. Bloods tests to diagnose stroke may include checking how fast the blood clots, whether the blood sugar is too high or low, and whether the person has an infection.
• Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a detailed image of the patient’s brain. A CT scan can show bleeding in the brain (a hemorrhagic stroke), an ischemic stroke, a tumor or other conditions. Doctors may inject a dye into the patient’s bloodstream to view the blood vessels in the neck and brain in greater detail (computerized tomography angiography).

• Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and a magnetic field to create a detailed view of the brain. An MRI can detect brain tissue damaged by an ischemic stroke and brain hemorrhages. A doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiography or magnetic resonance venography).
• Carotid ultrasound. In this test, sound waves create detailed images of the inside of the carotid arteries in the neck. This test shows buildup of fatty deposits (plaques) and blood flow in the carotid arteries.
• Cerebral angiogram. In this uncommonly used test, the doctor inserts a thin, flexible tube (catheter) through a small incision, usually in the groin, and guides it through the major arteries and into the carotid or vertebral artery. Then the doctor injects a dye into the blood vessels to make them visible under X-ray imaging. This procedure gives a detailed view of arteries in the brain and neck.
• Echocardiogram. An echocardiogram uses sound waves to create detailed images of the heart. An echocardiogram can find a source of clots in the heart that may have traveled from the heart to the brain and caused a stroke.

HOW ARE STROKES TREATED?

Knowing the time of onset of stroke is extremely important as some treatment options are most effective when given soon after a stroke begins.

The type of treatment will depend on the type of stroke.

Ischemic stroke

To treat an ischemic stroke, doctors must quickly restore blood flow to the brain. This may be done with:

• Emergency IV medication. Therapy with drugs that can break up a clot has to be given within 4.5 hours from when symptoms first started if given intravenously. The sooner these drugs are given, the better. Quick treatment not only improves a patient’s chances of survival but also may reduce complications. An IV injection of recombinant tissue plasminogen activator (TPA) – also called alteplase (Activase) or tenecteplase (TNKase) – is the gold standard treatment for ischemic stroke. An injection of TPA is usually given through a vein in the arm within the first three hours. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. This drug restores blood flow by dissolving the blood clot causing the stroke. By quickly removing the cause of the stroke, it may help people recover more fully from a stroke.

• Emergency endovascular procedures. Doctors sometimes treat ischemic strokes directly inside the blocked blood vessel. Endovascular therapy has been shown to significantly improve outcomes and reduce long-term disability after ischemic stroke. These procedures must be performed as soon as possible:
  • Medications delivered directly to the brain. Doctors insert a long, thin tube (catheter) through an artery in the groin and thread it to the brain to deliver TPA directly where the stroke is happening. The time window for this treatment is somewhat longer than for injected TPA but is still limited.
  • Removing the clot with a stent retriever. Doctors can use a device attached to a catheter to directly remove the clot from the blocked blood vessel in the brain. This procedure is particularly beneficial for people with large clots that can’t be completely dissolved with TPA. This procedure is often performed in combination with injected TPA.

The time window when these procedures can be considered has been expanding due to newer imaging technology. Doctors may order perfusion imaging tests (done with CT or MRI) to help determine how likely it is that someone can benefit from endovascular therapy.

Other procedures

To decrease a patient’s risk of having another stroke or transient ischemic attack, a physician may recommend a procedure to open up an artery that’s narrowed by plaque. Options vary depending on the situation, but include:

• Carotid endarterectomy. Carotid arteries are the blood vessels that run along each side of the neck, supplying the brain (carotid arteries) with blood. This surgery removes the plaque blocking a carotid artery and may reduce the risk of ischemic stroke. A carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions.
• Angioplasty and stents. In an angioplasty, a surgeon threads a catheter to the carotid arteries through an artery in the groin. A balloon is then inflated to expand the narrowed artery. Then a stent can be inserted to support the opened artery.

Hemorrhagic stroke

Emergency treatment of hemorrhagic stroke focuses on controlling the bleeding and reducing pressure in the brain caused by the excess fluid. Treatment options include:

• Emergency measures. If the patient is taking blood-thinning medications to prevent blood clots, they may be given drugs or transfusions of blood products to counteract the blood thinners’ effects. They may also be given drugs to lower the pressure in the brain (intracranial pressure), lower blood pressure, prevent spasms of the blood vessels and prevent seizures.
• Surgery. If the area of bleeding is large, a physician may perform surgery to remove the blood and relieve pressure on the brain. Surgery may also be used to repair blood vessel problems associated with hemorrhagic strokes. A physician may recommend one of these procedures after a stroke or if an aneurysm, arteriovenous malformation (AVM) or other type of blood vessel problem caused the hemorrhagic stroke.
• Surgical clipping. A surgeon places a tiny clamp at the base of the aneurysm to stop blood flow to it. This clamp can keep the aneurysm from bursting, or it can keep an aneurysm that has recently hemorrhaged from bleeding again.
• Coiling (endovascular embolization). Using a catheter inserted into an artery in the groin and guided to the brain, the surgeon will place tiny detachable coils into the aneurysm to fill it. This blocks blood flow into the aneurysm and causes blood to clot.
• Surgical AVM removal. Surgeons may remove a smaller AVM if it’s located in an accessible area of the brain. This eliminates the risk of rupture and lowers the risk of hemorrhagic stroke. However, it’s not always possible to remove an AVM if it’s located deep within the brain, it’s large, or its removal would cause too much of an impact on brain function.
• Stereotactic radiosurgery. Using multiple beams of highly focused radiation, stereotactic radiosurgery is an advanced minimally invasive treatment used to repair blood vessel malformations.

STROKE AND MEDICAL MALPRACTICE

Different Types of Medical Malpractice Stroke Lawsuits

Substandard stroke management is a leading cause of medical malpractice lawsuits in Ontario. In my experience as a medical malpractice lawyer, there are a number of different ways in which a patient may unfortunately experience negligent medical treatment for a stroke:

• Misdiagnosis. Stroke patients most typically present to the emergency room via ambulance although they may also present themselves. It is possible that a stroke patient may also present to a walk-in clinic or family doctor’s office. A stroke patient may exhibit all the signs and symptoms of stroke in a typical fashion and the diagnosis may nevertheless be missed by an inexperienced or busy physician. However, a stroke misdiagnosis is most likely to occur with less common presentations of stroke such as in young patients, women, minorities, and patients presenting with non-specific, transient, or posterior circulation stroke symptoms.
• Failure to investigate. If a physician suspects that a patient may be acutely suffering from a stroke, they have a duty to investigate this working diagnosis in a timely manner in order to direct treatment, if necessary. In this scenario, and depending on the clinical circumstances, the physician may not order the correct investigations to appropriately diagnose or rule out stroke. This may result in a false reassurance that the patient did not suffer a stroke when in fact they did, thereby depriving them of potentially life saving treatment. This may give rise to a lawsuit for negligent investigation of stroke.
• Failure to interpret imaging properly. The diagnosis of a stroke and potential treatment will turn on accurate interpretation of advanced imaging that may show clots in the arteries or bleeds in the brain. If abnormal imaging is mistakenly interpreted as normal, or the abnormality is not properly communicated to the treatment team, this may lead to a negligent interpretation of diagnostic imaging lawsuit. 
• Failure to initiate appropriate treatment. Once a stroke is diagnosed and if treatment is indicated, there may be instances where there is a delay in the initiation of treatment that would have significantly improved the outcome of the patient. The delay in initiation of treatment may simply be due to a delay in a physician ordering the treatment, or it could occur where the physician has ordered treatment but for whatever reason the hospital or nursing staff have failed to initiate it within a reasonable timeframe. There are instances where patients have suffered subsequent strokes while waiting long past the time that treatment should have been initiated to prevent a reoccurrence of stroke.

It is not only physicians that may be liable for a delayed diagnosis of stroke. A hospital may equally be liable if it failed to provide the needed resources in a timely manner to diagnose and treat stroke victims such as: adequate and competent nursing staff, timeless access to advanced imaging such as CT and MRI, and importantly operating room resources for endovascular procedures.

Stroke Treatment in Ontario

Not all hospitals in Ontario offer treatment for stroke, and not all hospitals that do offer stroke treatment necessary offer all types of treatment for stroke. According to CorHealth Ontario, the following is a list of regional stroke centres that offer pre-hospital, emergency, acute, and secondary prevention services for stroke:

• London Health Sciences Centre
• Hamilton Health Sciences
• Trillium Health Partners in Mississauga
• Unity Health Toronto
• Sunnybrook Health Sciences Centre in Toronto
• University Health Network in Toronto
• Kingston Health Sciences Centre
• The Ottawa Hospital
• Royal Victoria Regional Health Centre in Barrie (enhanced district stroke centre)
• Health Sciences North in Sudbury (enhanced district stroke centre)
• Thunder Bay Regional Health Sciences Centre

Damages from Negligent Stroke Treatment

The amount of financial compensation that a patient may receive from a medical malpractice lawsuit for negligent stroke care will depend on the extent of their disability related to the negligence.

It must always be kept in mind that a person who suffers an acute stroke may potentially have suffered a brain injury. Some of the brain damage may have occurred before any treatment was possible. Some of the brain damage may, however, have been preventable had appropriate treatment been initiated in a timely manner. It will likely come down to the opinion of a stroke neurologist to parse out what amount of disability is related to non-negligent medical care and how much is related to the negligence.

The majority of patients that have suffered a stroke will undergo some kind of rehabilitation to improve their ability to function, communicate and live independently. Much of this rehabilitation is offered at specialized in-patient stroke rehabilitation hospitals and would be covered under the Ontario Health Insurance Plan (OHIP).

However, once the patient is out of the hospital system, the cost of further rehabilitation, attendant (support) care, lost wages, etc. will fall on the stroke victim and their family. The financial consequences to a family can be enormous.

Proving a Medical Malpractice Stroke Claim

Proving any kind of medical malpractice claim in Ontario is challenging. Read here for more general information on whether you can sue for medical malpractice.

In order to prove a stroke negligence claim, you will need expert opinions from qualified and experienced physicians in potentially more than one area of specialization. At a minimum, the starting point would be for your lawyer to consult with a stroke neurologist to better understand the type of stroke you experienced, the related standards of diagnosis and treatment, and whether they were met in your case.

Additionally, you will need a stroke neurologist to prove whether your outcome would like have been better, and by how much, had proper treatment been received. 

You may need more than one expert in a stroke negligence claim. Additional experts that may be required might include an interventional radiologist, a neuroradiologist, a vascular surgeon, and a physiatrist. Much will depend on the facts of the individual case which is why consulting with a lawyer specialized in medical malpractice claims is essential to understanding your legal rights.

If you are concerned that you or a loved one has been harmed as a result of stroke negligence, you should seek legal advice from an experienced medical malpractice lawyer to learn whether you may be entitled to compensation.