Stroke is a leading cause of serious long-term disability and death. According to the CDC, in the United States, someone suffers a stroke every 40 seconds, and someone dies from a stroke every three minutes and 11 seconds. Each year, more than 795,000 people in the United States experience a stroke. From 2019 to 2020 alone, stroke-related costs in the U.S. were nearly $56.2 billion. While the risk of stroke increases with age, strokes can occur at any age. For example, in 2014, 38% of people hospitalized for stroke were under 65 years old-almost 4 in 10 stroke patients.
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Unfortunately, hospitals miss or misdiagnose a significant number of strokes. One study estimated that 12.7% of stroke admissions were potentially missed, translating to as many as 165,000 misdiagnosed strokes each year in U.S. emergency rooms. Patients presenting with headache or dizziness were disproportionately affected, and younger, female, and non-White patients were at higher risk of misdiagnosis. Overall, misdiagnosis is estimated to account for 40,000 to 80,000 preventable deaths each year in the United States, with a comparable amount of disability. Stroke is among the most common dangerous missed diagnoses.
Broadly, there are two types of stroke: ischemic and hemorrhagic. About 87% of strokes are ischemic, which occur when blood flow to brain tissue is blocked, usually by a clot or thromboembolism. Hemorrhagic strokes result from bleeding due to a ruptured blood vessel, often caused by a malformation such as an aneurysm.
Time is brain. Potential stroke patients require prompt evaluation, including the use of a stroke severity rating scale-preferably the National Institutes of Health Stroke Scale (NIHSS). All patients with suspected acute stroke should receive emergency brain imaging upon first arrival at the hospital to differentiate between ischemic and hemorrhagic strokes. This distinction is crucial because certain ischemic strokes can be treated with medication to dissolve the clot, restore blood flow, and mitigate brain injury. However, administering such medication to a patient with a hemorrhagic stroke can be catastrophic. A noncontrast CT scan is effective for excluding intracranial hemorrhage before treatment, and MRI is also effective. In certain cases, CT angiography or MR angiography with diffusion-weighted MRI is recommended.
Clot-dissolving medications, or thrombolytics, should be administered to eligible patients with ischemic stroke within 4.5 hours of symptom onset, unless contraindicated. The therapeutic benefit is highly time-dependent and should be initiated as quickly as possible. Because the time from symptom onset to treatment significantly impacts outcomes, treatment should not be delayed to observe for possible symptom improvement. Physicians must also be prepared to manage potential emergent side effects, such as bleeding complications and angioedema. Certain patients, as defined in clinical guidelines, should receive mechanical thrombectomy within six hours of symptom onset-an endovascular procedure to remove the occlusion and restore blood flow.
Hemorrhagic stroke disrupts normal blood circulation in the brain and increases intracranial pressure, which can damage or kill brain cells. It can also lead to vasospasm, further injuring brain tissue. Treatment generally involves medication, including clotting support, blood pressure management, and reduction of intracranial pressure. Surgery may also be necessary to repair a ruptured aneurysm or decompress the brain and relieve pressure.
A notable subset of strokes are posterior circulation strokes, which account for approximately 20% to 25% of ischemic strokes. These strokes are three times more likely to be misdiagnosed. Because the symptoms of posterior circulation stroke can resemble non-stroke conditions affecting the inner ear, such as benign paroxysmal positional vertigo or vestibular neuritis, it is vital for providers to promptly and thoroughly evaluate patients to determine if a stroke has occurred. Posterior circulation strokes may also be underscored on the NIH stroke scale, which prioritizes deficits from anterior circulation strokes, such as motor weakness and language impairment. Posterior circulation strokes, affecting the brainstem, cerebellum, and occipital lobes, often present with symptoms like vertigo, truncal or gait ataxia, dysphagia, and cranial nerve abnormalities-features not adequately captured by the scale. Providers must therefore remain vigilant and conduct timely, comprehensive evaluations.
The medical malpractice lawyers at Queller Fisher Washor Fuchs & Kool are experienced in litigating all types of misdiagnosed or improperly treated stroke cases. They have assisted patients and their families when a departure from accepted medical practice has resulted in delayed diagnosis or treatment of ischemic or hemorrhagic stroke.