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A competent malpractice defense would have almost certainly raised this point, and it's an extremely relevant point to raise. If you can't prove (by the 'more likely than not' standard in tort law) that the EM doc and neuroradiologist directly caused the patient's outcome by missing the diagnosis, a malpractice claim generally can't survive.
Thrombectomy is standard of care for an occlusion, not a subocclusive thrombus. Also, thrombectomy is rarely performed in the vertebral arteries because a complication there could result in distal injury or occlusion of the basilar which can have profound consequences. Thrombectomies are performed on on basilar occlusions but data are lacking and pretty mixed for these because of very high mortality and morbidity.
Correct, while there is clear evidence of improved outcomes in the anterior circulation the data is not as compelling for thrombectomy in the posterior circulation. Most stroke neurologist I know will push for it anyway due to the severity of disability one can get from posterior circulation strokes.
As per the trial radiologist opinion there was intradural, intracranial extensive dissection present to the base of the basilar. Bad situation but tPA is in a very grey area with known intracranial arterial dissection. Not read that way per the radiologist that missed the diagnosis but still. Intervention would have been potentially indicated for basilar occlusion but that would be ugly with a dissection.
To say someone is already done if they show up with stroke symptoms within a 4 hour window is malpractice. The guy clearly wasn't locked in when he showed up. Even if you don't give TPA, antiplatelets or anticoagulation reduce stroke risk following dissection. This is absolutely a case of malpractice. The cause for his stroke was missed on imaging, a neuro exam was not performed till the next day despite showing up with neurological complaints and disease modifying care was delayed.
I think the CTA read was potentially negligent. There is a gulf between the expert opinion and the actual read, and that was the main actionable data point, as we all know with unexplained stupor/coma CTA is the first and most urgent test (besides ativan trial, etc depending on exam). The Ed doc had poor documentation but the right actions were taken. There should have been a statement in there about tPA in terms of why or why not as well, but clearly tPA wouldn't have likely moved the needle on the outcome here.
Only thing that might have saved this guy would be endovascular intervention, and even then it's a big maybe. Clot retrieval is easier when the proximal artery isn't dissected. Pipeline stent could be attempted but there is a risk of jailing off the pontine perforators anyway. Sounds like the un-dissected vert was congenitally small. It would have been a difficult case / hail Mary pass.
Just a med student applying psych, but had a case of Locked In Syndrome during my psych clerkship and submitted a research article on it, the craziest thing I found on literature review was that 80% (something close to that, I forget the exact numbers but could reference the source if curious) of patients stated that they were happy with quality of life and didn’t want to die, and we talked about how we may have some underlying biases as being knowledgeable about Locked In Syndrome in general. Not that I’m saying you are wrong or anything, because personally I totally agree with how terrifying it is even with first hand experience, but just found it remarkably interesting.
The other reason I left myself full code “as long as I’m able to communicate” is because if the reality is that I can’t deal with it, I would theoretically be able to communicate that I want to be CMO. I had a patient locked in below the neck after a stroke once who could talk, but couldn’t breathe without the vent and he gave it the old college try for a few weeks but ultimately couldn’t imagine his life like that forever. He chose CMO and we were able to send him off with his family around him, high as a kite and laughing before drifting off to a comfortable end. I feel like although it was devastating, it was helpful for his family not to have to make the choice and to know that he was able to choose what he wanted. If I can spare my husband making the final decision, I will.
I am a Speech Therapist in a hospital. I remember reading that exact article in grad school. It stuck with me. I had a locked-in patient several years ago who was communicating in full sentences using only eye movement within a week from his stroke. I kept in touch with him and his family until he passed away last year. They invited me to the memorial service. They were grateful for the last years of his life, even though they were the most difficult. I will never forget that experience.