ER Failure To Diagnose Stroke

Case Overview:
A 57-yr. old male presented to the hospital ED with intermittent and progressive chest discomfort with SOB. On day of presentation, he developed some right hand and arm numbness with slight swelling. History of MI with angioplasty 15 years earlier, echo 4 years earlier with normal function; stress test two years earlier with 60% EF; hypertension, hyperlipidemia, GERD, peptic ulcer disease. In ER, his EKG showed no ST-T wave changes; chest CT was negative for PE; head CT showed no acute pathology; serial enzymes were all negative. On physical exam, there was no JVD and carotid pulses were 2+ bilaterally with no bruits. The next day he was symptom-free and discharged on low-dose aspirin (among other meds). 2 days later, patient awoke with slurred speech and right-sided facial droop, right-sided arm and leg weakness. Stroke workup disclosed: bilateral carotid Doppler with complete occlusion of left internal carotid artery; MRI showed acute stroke involving left MCA territory with complete thrombosis of left internal carotid artery at it origin and decreased left MCA flow. Now in rehab for serious residual deficits.

Issue:
1) Given negative head CT and carotid pulses 2+ without bruits bilaterally (and resolved Sx by time of discharge) at the first visit, was it standard of care to have done a carotid Doppler before discharging him?
2) If so, and if carotid Doppler had been performed, what would it most likely have shown, and would that have compelled emergent treatment that would have likely avoided this stroke two days later?

medQuest Expert Responses:

This is a very troubling case. this patient presented with primarily cardiac symptoms but also complained of right arm and hand numbness. the sensxory symptoms were enough to have a head CT scan ordered. Someone was was thinking TIA / stroke. In a man with the various risk factors for cerebro-vascular disease, the stroke work-up should have been done which would have included a carotid ultrasound and an echocardiogram. These are standard tests and the standard of care would have dictated these studies.  I suspect he had a near-total occlusion of the left internal carotid artery which became a total occlusion in the subsequent days leading to his left cerebral infarction. There is no way his left internal carotid went from being perfectly patent to a total occlusion over a period of days. When it showed a critical stenosis during his first admission with the TIA and chest discomfort, carotid endarterectomy would have been done to avoid the catastrophic result that occurred.The standard of care was not upheld in regard to this case and directly led to the eventual stroke.
Dr GB – Neurologist

I’m not sure that carotid Doppler is really the issue in this case. With or without carotid Doppler, the claim would have to be that TIA was or should have been strongly suspected, and that in a patient who was already on aspirin (as he presumably would have given the history of CAD), a second or alternative anti-platelet agent should have been initiated for stroke prevention.
Dr JK – Emergency Room