Patient Suffers Stroke Following Failure to Receive TPA

Case Overview
Joan is a 29 year old woman with 3 pregnancies, and 3 viable healthy births. She is married and also has one stepdaughter. She has a history of migraine headaches, that became worse during pregnancy and she consulted with the neurologist. Nothing was done at that time because she was pregnant. She was placed on Topamax, once her tubes were tied. Topamax had controlled the headaches for quite some period of time. She had her tubes tied in the spring of 2012, but because of abnormal uterine bleeding she had a hysterectomy in March. Her tubes and ovaries remained intact so there was no hormone replacement. She also had a history of mitral valve prolapsed and regurgitation.

In April  she was at the grocery store, when she felt fatigued and lightheaded. When she went to get her daughter out of the car seat her left side went numb.

On April 15, she was having left sided weakness, dizziness, heart palpitations blurry vision in the left eye and some slurred speech. She had an EKG and CT without contrast. She was told by the emergency physician that she was too young to be having a stroke and her EKG was normal. They diagnosed labyrinthitis and she was treated with antivert (she had scarring in her left ear that she says had been there.) The ER told her to follow up with her family doctor. She did that and the family doctor ordered antibiotics based on the emergency room physicians diagnosis. The symptoms remained and she followed up with her family physician again on May 31. The PCP mentioned that maybe the issues were heart related and she should follow up with the cardiologist.

A rhinoplasty was scheduled for July, the plastic surgeon wanted an additional EKG because the April EKG was read as abnormal. PCP cleared for surgery.

July 2 rhinoplasty was done. She had no post-operative problems.
July 22 PCP visit. Complained of dizziness, forgetfulness, short- tempered, palpitations and sinus pressure. PCP upped topamax thinking she was experiencing migraines without the headache.
July 24 Cardiology appointment. EKG was normal but placed on Halter monitor for 24 hours and results were normal.
July 30: walked out of a store and could not remember how to get home. She stayed for some time and then was able to get home and went to sleep.
July 31: Joan awoke with an excruciating headache, had numbness, pins and needles on her left side , she was still confused. No peripheral vision on the left side. She went to the ER. She was given a shot of pain medication for the headache. She was released with a referral to neurology and prescriptions for tramadol and Phenergan.
August 1: returned to the ER left side was now weak. She was dragging left leg and foot. He called neurologist she had seen several years before for her migraines who said not to scan her and she should follow up with him the following day.
August 2: Neurology appointment: Physician said she would be fine and should start feeling better soon.
August 4: call to neurologist by husband headache still really bad no relief , sleeping and vomiting. Neurologist said these episodes can last 2 weeks.
August 7: contacted PCP and told her that she was concerned something else was wrong she still did not feel better. PCP relayed message that PCP had confidence in neurologist diagnosis of stress induced numbness.
August 14: with family all of a sudden bad headache confusion and did not recognize her children. Call to neurologist who wanted to see her the following day.
August 15: sees neurologist MRI done and confirms a stroke. MRI: Impression: Favor sub acute infarction with enhancement involving 2 areas of the right infer medial temporal lobe and associated small amount of hemorrhagic staining, including involvement of the hippocampus. Small linear configuration of pre-contrast hyper intense T1 signal and enhancement suggests possibility of localized cortical venous thrombosis or even involvement of a small developmental venous anomaly. Arterial ischemic disease is not excluded. Consider further evaluation with MRA. Recommend follow up scan in 6 weeks to exclude progressive disease process. Remote right thalamic infarction.

She has switched neurologists. New neurologist did a MRA which still shows clot. A clotting disorder has been ruled out. She had a loop event recorder placed to make sure that she had no atrial fibrillation that was negative and the loop recorder has since been removed.

Joan is a young woman who has significant left sided weakness, her fine motor control is limited with her left hand. She has short term memory issues. She has some decrease in her peripheral vision, although that has improved some. She feels somewhat short tempered and frustrates easily.

She had been told that if she had received tPA in the ER on July 31, 2013 that it likely would have prevented her problems.

The questions that we have: was imagining required by the standard of care on July 31? Was other testing required? Should she have been admitted and the cause of her symptoms been more thoroughly investigated? Would she have been a candidate for TPA?

Issue
Was imaging required by the standard of care on July 31,2013?
Was any other testing required?
Should she have been more thoroughly worked up?
Would she have been a tPA candidate on July 31, 2013? would tPA have prevented the permanent injury?

MEDQUEST EXPERT OPINIONS:

It sounds like there are some standard of care issues. This patient has a history of what sound like complicated migraine attacks manifest by left sided symptoms, slurred speech, visual symptoms, and cognitive problems. This history could have led to a delay in her diagnosis. However, the presentation on 7/31 sounds like it was more profound than usual which led to the ER visit. She at least warranted an imaging study of the brain on that visit which may or may not have shown an acute infarct (which is likely when it happened).

The issue of administering tPA on that visit is a different story. One does not get tPA if they wake with stroke symptoms since it is a strict 3-4.5 hour window. If she woke with symptoms, there is no way of knowing when the stroke occurred. Thus, she was not a tPA candidate. Whether it would have helped is a moot issue. In fact, if she did get it, there would be reason to sue for any adverse result which occurred. Also, there is mention made of a “clot” on a subsequent MRA. If this was a venous clot with venous infarct, tPA could have been disastrous since these types of infarcts tend to bleed. Overall, she was not a tPA candidate.

The standard of care revolves around the lack of imaging and not admitting her on 7/31. In the big picture, it probably made no difference in the eventual outcome. But progressive or recurrent infarcts can peak in the first 72 hours and these would have been quickly evaluated and potentially treated. If a venous occlusion, anti-coagulation would have been instituted.

Tough case for everybody involved.

This is a complex case with several issues, questions. tPA would have icnreased probablility of good outcome by about 38%, but, note there were small areas of hemorrhage which could be used to prove tPA would have increased the risk of bleed.
Dr DB – Neurologist

this is a case against her doctors – particuarly against her neurologist. Her care from the neurologist from day one was remarkably bad.

This is not a case against the ER doc. “Ryan awoke with an excruciating headache, had numbness, pins and needles on her left side , she was still confused. No peripheral vision on the left side. She went to the ER. She was given a shot of pain medication for the headache. She was released with a referral to neurology and prescriptions for tramadol and phenergan. ” Since she awoke with the headache, etc, she was not a tPA candidate. One MUST know the duration of symptoms in order to be considered for tPA.
Dr KB – ER