Medical Malpractice: The Stroke Case
You’re lying in bed, and suddenly, you cannot feel one side of your body, your face droops, and you are slurring your words like you’ve just been given a full syringe of Novocain. You become disoriented and confused.
You’re having a stroke, as will approximately 800,000 other Americans this year.
A “stroke” describes the clinical condition in which a patient suffers disruption of blood flow to parts of the brain, resulting in altered mental status and neurological deficits. This condition ranges from minor transient ischemic attacks (TIAs) to blood flow disruptions so severe that it causes death. A more minor event, like a TIA or small stroke, can also be a precursor to a more severe stroke.
The medical approach to the diagnosis and treatment of a stroke follows certain well-defined pathways, guided by principles of evidence-based medicine. When medical providers fail to follow these established pathways and an otherwise preventable or treatable stroke goes on to cause significant injury or death, there may be an actionable malpractice case.
Obviously, the best way to avoid the harmful effects of a stroke is to prevent it from occurring in the first place. Stroke prevention strategies begin with assessing the patient’s stroke risk. Certain underlying medical conditions, like atrial fibrillation, increase the risk of a stroke. In a patient with atrial fibrillation, the heart’s chambers beat out of rhythm, allowing blood to pool in the left atrium (upper chamber), significantly increasing the likelihood that blood will clot. When these blood clots are then pumped out of the heart to the brain, the clot can block off one the blood vessels in the brain, preventing blood flow to part of the brain and causing a stroke. This is sometimes referred to as an “ischemic stroke,” because the clot leads to inadequate blood flow, or “ischemia.” Approximately 9 in 10 strokes are ischemic strokes.
Ischemic strokes—particularly in patients with atrial fibrillation—are often preventable. To determine stroke risk, those with atrial fibrillation must be assessed using a scoring system, such as the CHADS or CHADS2 score. These scoring systems can clinically predict the risk of stroke in a patient with multiple risk factors for ischemic stroke (such as hypertension, vascular disease, old age, etc.). If the risk for stroke is high enough, doctors must recommend that the patient receive prophylaxis in the form of anticoagulation medication (e.g., Coumadin, Pradaxa, Xarelto, Eliquis) to reduce the risk of blood clots and therefore the risk of an ischemic stroke.
It is worth noting that medications come with risks of their own, depending on the nature of the clotting agent and the profile of the patient. We often see potential cases concerning coagulated patients who suffer injuries are a result of a failure to properly manage a patient with an elevated risk of bleeding.
Another common cause of ischemic stroke is artery dissection. This occurs when there is damage to the interior lining of the artery (the intima). When the intima is damaged, a flap can form and serve as the nidus for a blood clot (thrombus) to form. The blood clot can occlude the artery which prevents blood from flowing to the brain, or pieces of the clot can break off, travel downstream, and clot off smaller blood vessels in the brain. Either way, the lack of blood flow will cause an ischemic stroke. Vertebral artery dissection is a leading cause of stroke in younger patients, particularly those who are at higher risk, such as women undergoing labor or those with chronic hypertension.
Artery dissection and thrombus may be treated with antiplatelet medications, like Aspirin or Plavix. These medications, used individually or in combination with blood thinners, have demonstrated high levels of success in preventing ischemic stroke.
If a patient has risk factors or a precursor event (like an artery dissection) and doctors fail to properly assess the risk and to prescribe medications to reduce the risk of stroke, it may be possible to succeed with a malpractice case.
Some people suffer massive strokes seemingly out of the blue with little or no warning. However, others may first experience a precursor event, like a TIA or more minor stroke. They are “precursor” events, because they can lead to a more major stroke if not properly treated.
When a patient has a “precursor” event, they should be fully worked up to determine if there are ways to address the root cause to prevent future stroke. The patient may require anticoagulants, antiplatelet medications, medications to treat hypertension, or an endovascular procedure to address stenosis or thrombosis, such as thrombectomy or bypass grafting for re-vascularization.
Commonly, stroke cases involve failure to properly manage a patient who has suffered from an acute stroke. There are specific guidelines for how to manage an acute stroke which must be followed to comply with the standard of care.
An acute stroke is a medical emergency. When a patient has an ischemic stroke, the goal of treatment is to remove the obstruction and reperfuse the part of the brain to which blood flow has been disrupted. Treatment must occur within a relatively short window of time, or the patient’s stroke injuries will be irreparable.
There are essentially two methods to treating an acute stroke: medication and surgery.
The medication is called Tissue Plasminogen Activator (tPA). When tPA is administered within several hours of the onset of an acute stroke, it has the ability to restore blood flow to the affected part of the brain. When a patient presents to a hospital with an acute stroke, doctors are required to determine the timing of the patient’s onset of symptoms, the severity of the stroke, and the type of stroke (i.e., ischemic, or hemorrhagic). For an ischemic stroke, which is severe, and onset of symptoms occurring within three hours of arrival at the hospital, tPA should be administered (unless otherwise contra-indicated).
Although the window for administering tPA is up to three hours after onset of symptoms, the sooner after symptom onset tPA is given, the greater its efficacy. This is important in proving medical causation in a malpractice case: the earlier the patient arrives at the hospital following onset of symptoms, the better the argument that administering tPA alone would likely have resulted in an appreciably better outcome.
For certain types of ischemic strokes, particularly those involving large vessel occlusions, the probability of a patient having a good outcome can be significantly increased using endovascular treatment, such as thrombectomy, on its own or in combination with tPA. A “thrombectomy” is an interventional procedure which involves mechanically removing the blood clot from the artery—either using a catheter threaded into the artery or directly through surgical incision. One benefit of thrombectomy is that the window for treatment is considerably longer than the three-hour window for treatment with tPA.
If a patient is a candidate for thrombectomy, but the medical provider does not perform thrombectomy within the applicable window of time, this may serve as the grounds for a medical malpractice case.
Discuss Your Stroke With a Medical Malpractice Attorney Today
The impact of a severe stroke is devastating. Depending upon which parts of the brain are injured, a stroke victim may lose the ability to walk, talk, process information, control emotion, or even lose all motor function (“locked-in” syndrome). Stroke victims often are unable to return to work. They may require expensive medical care, therapy, and help with normal activities of daily life for the rest of their lives.
Under the right circumstances, a stroke victim may have a medical malpractice case based upon the failure to properly prevent or treat the stroke. Contact Gideon Asen, LLC, to discover your legal options.