How to Avoid Stroke-Related Medicolegal Disasters

ACEP News
July 2009

The brain's posterior circulation is 'undoubtedly our greatest area of risk as emergency physicians.' Dr. Pancioli

By Bruce Jancin
Elsevier Global Medical News

New Orleans -- Strokes in young patients and posterior-circulation strokes collectively make up less than 15% of all ischemic strokes but are a disproportionate cause of lawsuits against emergency physicians, Dr. Arthur M. Pancioli said at the annual meeting of the Society for Academic Emergency Medicine.

Recognizing that these are two problem areas, along with careful documentation of neurologic exam findings, will go a long way toward limiting stroke-related medicolegal risk, according to Dr. Pancioli, professor and vice chair for research in the emergency medicine department at the University of Cincinnati.

Less than 5% of all ischemic strokes occur in patients younger than 40 years, but that's still a substantial absolute number because stroke is so common.

"They're going to come in the 30-year-olds. They're going to come in the 20-year-olds. They're out there, and they get missed a lot," he said.

Moreover, a bad outcome in a young patient with a delayed diagnosis multiplies the damages in court manyfold, Dr. Pancioli noted.

In reviewing numerous medical charts and legal depositions by defendant physicians, Dr. Pancioli said one of the most dangerous phrases he regularly encounters is, "TIA wasn't on my differential because of the patient's age." The possibility of stroke should be considered regardless of age in patients who present with sudden onset of focal neurologic deficits, he emphasized.

Strokes located in the posterior circulation are notoriously difficult to diagnose because of their varied and often confusing presentation. These strokes tend to be particularly disabling, and result in large damage claims.

"The posterior circulation is undoubtedly our greatest area of risk as emergency physicians. The back side of the circulation will bite you squarely on the backside," Dr. Pancioli continued.

He is a strong advocate of the "dizzy-plus" rule as a guide to the possibility of a posterior-circulation ischemic stroke. The rule holds that while a patient who reports only dizziness may well be okay, the patient who complains of dizziness plus something else--such as weakness, numbness, or visual deficit--should be considered as having a possible stroke in the back of the brain until proven otherwise.

"A lot of these patients with posterior-circulation stroke come in just a little bit bad. They're dizzy, a little bit weak, a little bit numb. Three hours later, they're number and weaker. Twelve hours later, they're worse," he explained.

"Most of the time they don't have enough symptomatology for you to be able to say, 'I want to treat this patient with TPA [tissue plasminogen activator] right now.' But they're giving you enough warning that you should get someone else involved who might work them up further and maybe do something fancier. Don't carry these patients alone," Dr. Pancioli advised.

Many physicians worry about hemorrhagic stroke as a complication of giving thrombolytic therapy for ischemic stroke. The literature suggests that such cases account for no more than 1 in 30 stroke lawsuits. Nearly all the rest involve failure to give thrombolytic therapy.

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