ER Failure to Dx and Treat Stroke

Patient, a 40 year old female African American visited the Emergency Department on June 11th due to increasing instances of debilitating migraines. The CT-Scan came back negative and she was released to follow up with a neurologist for possible MRI. Appointments were not made.

Three weeks later she returned to the Emergency Department and had after developing aphasia overnight and was unable to communicate beyond one or two word sentences. The staff ignored the new symptoms, performed no further studies and had her involuntarily committed to their mental health unit, where she was detained for a week. By the second day in the mental health ward the aphasia was wearing off.

On the last day in the Mental Health unit the patient finally got her requested neuro consult. The neurologist suggested that she follow up in his office the next day. He subsequently ordered an MRI while awaiting insurance approval. The patient was afraid to wait and checked into a 2nd Emergency Department. The staff there immediately took a CT Scan and compared it with the one from Hospital # 1 on June 11th. A lesion was found on the brain and an MRI taken the next day, revealed that she had had an AVM (stroke) on July 17th. She had a craniotomy to remove the lesion. She suffers memory loss, balance issues and required speech and occupational therapy.

ISSUE: Could the stroke have been prevented? Did the one month delay change the type of surgery that was necessary?

medQuest Expert Responses:

Interesting case and there are several levels to address.
If this patient had an AVM, it was there from the start and perhaps missed on the first CT scan that was done for headache on 6/11. It can legitimately be missed on non-contrast scans. No foul on doing a non-contrast CT scan the first time on a patient who presents in the ER with headache to rule a bleed. The ER was correct in referring her to a neurologist for headache management. Most probably, a neurologist would have done an MRI and found the AVM. It was the patient’s fault for not following up with a neurologist as the ER recommended.

When she presented with aphasia 3 weeks later, the ER was incorrect in not ruling out an orgainic cause for her speech difficulty and assuming it was psychogenic in nature. I am surprised that Psychiatry did not require neurologic clearance before admitting her to Behavioral Health. Eventually, imaging studies revealed an infarct which was likely due to thrombosis of the AVM which was found on MRI. She eventually underwent resection of the AVM leaving her with residual neurologic symptoms. I can’t say whether the residual symptoms are due to the surgery or from the prior stroke.

Bottom line: The AVM would have been found sooner, presumably before the stroke occurred, if the patient had seen a neurologist after the first ER visit on 6/11. The fact that she was not taken seriously when presenting with aphasia was wrong but it did not affect the final outcome.
Dr GB – Neurologist

Yes, it likely could have been prevented.
Dr DB – Neurologist