Posted: 03/01/2024
A stroke (often called a brain attack) occurs when the blood supply to the brain is either cut off or there is a haemorrhage, leading to the death of brain cells within hours. The effects of a stroke depend on where it takes place in the brain, how quickly it is recognised and treated, and then how substantial the damaged area is. Time is very much of the essence and the sooner a stroke is treated, the better the chances of survival and limitation of injury.
There are two major types of strokes: ischaemic and haemorrhagic. An ischaemic stroke is caused by a blockage (a clot, also known as a thrombus) cutting off the blood supply to the brain. This is the most common type of stroke. A haemorrhagic stroke is less common and is caused by bleeding in or around the brain.
Stroke claims may require detailed analysis of many aspects of a patient’s medical treatment and independent evidence from experts in linked, but niche specialties. This article considers the specialties involved in stroke diagnosis and treatment, explaining how they are likely to contribute, and what the medico-legal issues arising out of that treatment may be.
Where there is a suspected stroke suffered, paramedics will be involved in the initial examination, and undertake the first line of treatment. They are the first people to obtain a medical history of what has happened and when. Particularly for suspected stroke sufferers, a record of the timing of the onset of any neurological abnormality is crucial.
There will also be an initial FAST assessment, where facial weakness, arm/leg drift, speech impairment and time will be recorded as either positive or negative. Following assessment, a decision will be made by the paramedic team as to whether the patient needs taking into hospital or not.
Upon arrival at A&E the paramedics delivering the patient should provide the department with the patient’s medical history and explain the timing of the onset of any neurological abnormality where there is a FAST positive diagnosis. A request for the patient to receive a rapid evaluation should be made.
Failures to properly record the onset of neurological abnormality, or downgrading a positive FAST result unnecessarily (for example, if symptoms appear to improve) could mean the paramedic team do not pre-alert the A&E department ahead of the transfer of the patient. As a result, there may not be a stroke-competent person available to carry out an urgent assessment. Any delay in the early-stage diagnosis of a stroke could have significant consequences for the patient’s prognosis and treatment, as discussed below.
The patient will be assessed again in A&E. A CT head scan should be undertaken as quickly as possible and within 60 minutes of arrival, as part of the differential diagnosis process. Failures to interpret the CT scan accurately for intracranial abnormality, even when subtle, may result in a suspected stroke diagnosis not being made and the stroke team not being involved. Sadly, this can delay or stop time sensitive treatment from taking place.
There should be involvement from the stroke team for consideration of the nature, location, and extent of the stroke, be it ischaemic or haemorrhagic. Even where a CT scan shows no abnormality at an early stage, as a potential stroke patient, consultation with the stroke team will be ongoing.
A stroke physician will monitor neurological observations to reach a diagnosis. Where the stroke is ischaemic, the stroke physician will consider whether the patient is suitable for thrombolysis: treatment with medication to disperse the clot and return blood supply to the brain. This is normally given as soon as possible after a plain CT scan has excluded intracranial bleeding. This form of treatment is particularly time sensitive and, in most cases, needs to be given within four and a half hours of the onset of stroke symptoms. As such, any delay up to this point in treatment will have a significant impact on the effectiveness of thrombolysis.
Alternatively, a stroke physician may consider thrombectomy: surgery to remove the clot. As with thrombolysis, this treatment is also time sensitive, being most effective within the first six hours of the onset of neurological symptoms.
Complications can occur where there is doubt regarding the neurological symptoms of the patient, or where those symptoms fluctuate in intensity. If this is the case, the physician should request a CT angiogram, which is a scan combined with an injection of dye to produce an accurate picture of blood flow. The results of this are likely to demonstrate the cause of the problem and therefore should be carried out as soon as possible after the presentation of unclear or inconsistent neurological symptoms.
It may be necessary to transfer the stroke patient from a regional centre to a neurological centre for treatment, depending on the availability of the physician, radiological and theatre offering. We have seen cases of confusion regarding the referral pathway and the delays caused can be life changing. If transfer is necessary, summoning an ambulance and preparing the patient should be undertaken at the earliest opportunity, but ultimately this depends upon a range of factors including vehicle and crew availability, which can take time.
Thrombectomy is a surgical procedure performed by interventional neuroradiologists. Guidance from CT scans is used during the procedure, which involves insertion of a mesh into the artery, removing the clot and restoring blood flow to the brain. It is absolutely a time critical procedure in order to be successful. However, prompt removal of the thrombus halts the progression of the stroke and allows the brain to recover, so far as possible, and many patients do well after thrombectomy.
Where the patient is not suitable for thrombolysis or thrombectomy, either due to the location of the clot, or due to the passage of time after the onset of symptoms (ie, it is too late), the stroke physician may well involve the neurosurgery team for consideration of life-saving surgery instead. This emergency surgery is performed by a neurosurgeon, a specialist in surgery of the brain and spinal cord. Issues can arise where there is limited availability of neurosurgeons or theatres, such as overnight and over weekends.
Craniotomy surgery for haemorrhagic strokes reduces brain pressure by opening the skull to expose the brain, access and control bleeding, and reduce pressure in the brain caused by excess fluid. The surgeon will repair damaged blood vessels and ensure there are no blood clots present. Craniotomy does not limit the damage caused by a stroke but can be lifesaving, particularly for younger patients, who are more vulnerable to suffering dangerous increases in intracranial pressure.
Decompressive craniectomy may be performed after an ischaemic stroke. A significant proportion of the skull is removed, effectively to give the injured part of the brain more space, allowing the ischaemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, avoiding secondary damage due to increased intracranial pressure.
A stroke can leave someone facing difficulties with movement, speech, memory, and vision. It can also cause psychiatric injuries such as depression and anxiety. Recovery takes time and a great deal of patience. Returning to work is a huge milestone for many. Some may need care for the rest of their lives.
Ongoing rehabilitation for a stroke patient will be overseen by the neurology and/or neurorehabilitation teams. The nature and extent of the care will be tailored to the patient, depending on how the brain has been damaged and the level of residual disability.
The hospital’s stroke unit should provide a specialist stroke service focused on the rehabilitation of patients, and neurologists will work within a multidisciplinary team to support the patient’s recovery. Support from occupational therapists, speech and language therapists and clinical neuropsychologists may also be involved.
Many patients who suffer from a stroke may require long-term support from other professionals such as physiotherapists or professional care givers in the community upon leaving hospital to help regain independence. Before transfer of care from hospital to home, it should be established that the patient has a safe and enabling home environment according to NICE guidelines. This could include ensuring there are the necessary pieces of equipment and adaptations to support independent living.
Multidisciplinary rehabilitation should continue at home. For example, physiotherapy sessions will assist with strengthening muscles and overcoming or reducing mobility issues, whilst speech and language sessions will benefit those with communication difficulties.
This article was co-written with Ellen Banks, trainee solicitor in the clinical negligence team.
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