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
Ian L. - November 2, 2020 3:38 PM
What of the HINTS exam and MRI-ANGIOGRAM ?
Mike W. - November 2, 2020 4:52 PM
Certainly good thoughts!!
M