A 36 year old man began to suffer garbled speech, vomiting, and left-sided weakness. His wife, who was a nurse, recognized the symptoms as a potential stroke and called an ambulance.
The man was taken to the nearest emergency department. He was examined and a Code Stroke was
called. A CT/CTA was done, and was reported as normal. The physician in the emergency room called for consultation with an international radiologist and a neurologist (members of the Stroke Team). They decided not to give the patient tPA (the “clot-busting” drug). The neurologist did not come to examine the man within the 4.5 hour window for administration of the drug.
Later, the man’s emergency medicine, neurology, and neurosurgery experts testified that this series of events was a breach of the standard of care. The Stroke Team raised the possibility of administering tPA, but decided against doing so. The literature showed, however, that tPA would have been helpful in the type of stroke the young man had.
Later same day the man was taken to the emergency room, a MRI showed two “small vessel” strokes in a confined space and very close to the brain stem. The hospital was a primary, not comprehensive, stroke center, and so had no neurosurgery coverage. The man’s experts later stated that due to the location of the strokes, there was a likelihood of edema and obstructive hydrocephalus. They also pointed out that if this problem should arise, it is to be addressed by a neurosurgeon.
On the second day, when the consulting neurologist never visited the man, the situation worsened and the man was transferred to the ICU. A new CT showed that hydrocephalus and edema were indeed causing mass effect. The man developed a Cushing’s reflex, the precursor to brain stem herniation and death. He was then transferred to a nearby tertiary care center and surgery was performed. The surgeon described the herniation as “impressive.”
The young man survived, but despite extended convalescence, was left with permanent neurologic deficits.
The case was resolved without mediation.
