Stroke in the United States
There are 795,000 new or recurrent strokes per year in the United States. Stroke is the fourth leading cause of death in this country.
Stroke occurs when the flow of blood carrying oxygen and nutrients to healthy brain cells is disrupted, due either to a vessel bleed or a blockage within the blood vessel. If the blood supply is not quickly restored it would lead to death of the brain cells (an infarction) that are supplied by the affected vessels.
Ischemic and Hemorrhagic Strokes
The two major types of stroke are identified as hemorrhagic (due to a bleed), and ischemic (due to a blockage). The large majority of strokes are due to ischemia resulting from a blockage in the vessel and can be treated by dissolving or removing the blood clot or thrombus and restoring blood flow. Time is of the essence when relieving the blockage, which is why stroke centers coined the phrase "time is brain" when referring to stroke treatment.
Most legal cases arise when the stroke is not promptly diagnosed or treated in the emergency room, costing the patient a significant opportunity for a good outcome. If one can relieve the blockage before permanent damage occurs, significant disability can be avoided.
Treatment of Ischemic Strokes
The standard treatment to relieve a clot or a thrombus is the administration of a "clot-busting drug" known as tissue plasminogen activator or "tPA" which can be administered intravenously for 3 to up to 4.5 hours after symptom onset. If the patient arrives to the emergency room more than 3 to 4.5 hours after symptom onset, there may be advanced treatment options that are available to dissolve and/or remove the clot including:
1) The administration of the clot busting drug "tPA" through a catheter directly to the clot;
2) The use of mechanical devices to remove the clot; or
3) A combination of these treatment approaches.
The accepted time windows for these advanced treatment options range from 6-8 to up to 24 hours after symptom onset, depending on the location of the blockage and other factors. With all of these treatments, the earlier the treatment is administered, the better the chance of avoiding significant disability.
Treatment of Hemorrhagic Strokes
This type of stroke, accounts for perhaps only fifteen to twenty percent of the strokes, but can be similarly devastating as brain tissue is deprived of blood supply due to the "rupture" of the artery carrying blood to the affected region. Once a rupture occurs, timely diagnosis and emergent intervention by a well trained and experienced neurosurgeon or interventional neuro-radiologist, is needed.
At times, depending upon the circumstances, techniques less invasive than open surgery can be successfully used to treat. At times, these strokes are preceded by a complaint of the onset of "the worst headache of my life," and an expansion of the wall of the artery can be discovered radiologically before rupture allowing, at times, for treatment to be offered before bleeding occurs.
Failure to Treat Signs and Symptoms of Stroke On a Timely Basis
Most medical negligence claims involving stroke revolve around the failure to diagnose and/or treat the signs and symptoms of a stroke on a timely basis. Over the past several years more and more hospitals have applied for certification to become either a "primary" or "comprehensive stroke center", requiring that the hospital follow the guidelines of the American Heart Association and the American Stroke Association (AHA/ASA) for treating stroke.
Failure of a hospital certified as a stroke center and its stroke team to work up and treat its patient in accordance with the AHA/ASA guidelines may form the basis for a claim of negligence and the breach of standards. Even at hospitals that are not certified as stroke centers, certain standards must be met in recognizing the signs and symptoms of stroke and acting promptly to work up and either treat the eligible patient or arrange for transfer to another hospital that can provide the necessary treatment under accepted medical standards. Not only can the doctors involved in the stroke care be held responsible, but the hospital itself can be held to account for its failure in having the necessary facilities, equipment, policies, and staffing in place to assure prompt and proper stroke care.
With the availability of telemedicine and interactive video access to specialists at "comprehensive" centers capable of providing the most advanced stroke treatments, there is little basis for failing to offer patients potentially life-altering stroke care to eligible patients at least by transfer to another hospital.
Proving a Causal Connection in the Stroke Case
As with all medical negligence cases, proving substandard or negligent care is only half of the battle. What must also be proved in each malpractice case is the causal connection between the claimed negligence and the harm. It is the person bringing the case who must prove this causal connection in each case. Where the underlying condition (that is, the clot or blockage which precipitated the stroke) pre-exists the negligent care, one must show that proper diagnosis and timely treatment would likely have resulted in a significantly better result.
Given the risks associated with treatment, and the fact that treatment will result in a good outcome in only a certain percentage of cases, establishing the likelihood of a good or significantly better outcome from what is a serious medical condition is the most difficult part of proving the stroke case in court. As treatment methods for relieving clots or blockages improve and the success rates from treatment become higher, the ability to establish the causal connection may become easier in the future.