Medical Legal Briefs: Stroke Mimics

Medicolegal Briefs: Stroke Mimics

Mike Weinstock, MD and Matt Delaney, MD

• This is the first of 3 episodes focusing on litigation related to stroke care.

CASE: A young woman presents with sudden onset of headache, slurred speech, right-sided weakness, dizziness, and vomiting. On EMS arrival, she is noted to have a headache and right-sided tingling. Her Cincinnati prehospital stroke scale is normal.

• She is seen quickly in the ED where a noncontrast CT of head is ordered and she receives a “migraine cocktail.”
• Weakness on one side was followed by numbness on the other side. After a normal CT the diagnosis of complex migraine is made.
• A neurologist is contacted and an MRI is ordered but there is delay; the MRI reveals an ischemic stroke in the cerebellum. The patient dies in hospital.
• The plaintiff sued for a failure of diagnosis and claimed that a “code stroke” should have been activated in the ED.
• The defendant argued that the exam was changing and inconsistent with stroke.
• The decision was for the plaintiff.
• Medicolegal concernsidentified:
  • There was no detailed neuro exam in the ED chart.
  • An NIHSS score was not recorded.
  • The above are especially pertinent because the family thought it was a stroke and that the ED physician was dismissive of their concern.
  • When the patient’s symptoms changed, there was little record of a reassessment.
  • After the MRI result came back, the ED physician went back in the record and added some documentation about how stroke was in the differential diagnosis. This was a death blow to the defence’s case. Remember that the metadata in the electronic medical record times all of the entries.
• A stroke mimicappears to be a stroke but it’s not. Mimics account for 15-30% of all stroke (mis)diagnoses.
  • The most common mimics are seizures, migraines, and functional (psychiatric) disorders.
  • Mimics are more likely in patients without any stroke risk factors.

PITFALLS

• A stroke chameleon may not look like a stroke but it is a stroke. Cerebellar strokes often present this way.

RELATED SEGMENTS

C3 - Stroke - Stroke Mimics

EMA 2015 October Abstract 15: Safety Of Intravenous Thrombolysis In Stroke Mimics: Prospective 5-year Study