In light of National Stroke Week across Australia, we shed some light on what strokes are, their symptoms, and how to test for early signs.
Types of StrokeThe World Health Organisation first defined a stroke in the 1970’s as a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours”. This definition is important in that it differentiates between an actual stroke and symptoms that appear similar to a stroke but are non-vascular in nature.
A stroke occurs when there is a major interruption of the blood supply to the brain that decreases the supply of oxygen to the brain cells resulting in a permanent injury to the brain. Alternatively when a blood vessel that surrounds the brain bursts, blood leaks into the brain cavity which also decreases oxygen to the brain cells with the same result.
The first scenario is usually caused by a blood clot, which is often located in another part of the body and travels to the brain through the blood flow in the arterial system. This type of stroke is called an ischaemic stroke and more than four in five people who suffer a stroke will have this type.
The second scenario is experienced by people who may have had longstanding hypertension (high blood pressure) or are on anti-coagulant medication for hypertension or they may have a congenital defect such as a cerebral aneurysm. This type of stroke is called a haemorrhage stroke and occurs far less frequently that an ischaemic stroke. Less than one in five stroke victims suffer from this type.
Very often, people can experience transient but acute stroke-like symptoms, usually for a period of up to 24 hours, which in medical terminology is known as a stroke mimic or a mini stroke. Some typical symptoms include:
- Severe migraine headaches that do not respond to pain medication;
- Light headedness;
- Loss of vision;
- Dizziness; and
- Tingling or a change in sensation in the face or on one side of the body, usually in the arms or legs.
SymptomsThe National Stroke Foundation recommends the FAST test to check for stroke symptoms. This test involves asking the following questions:
F - Has their face drooped? A - Can they lift both arms? S - Is their speech slurred and do they understand you? T - Time is critical. Call 000.
Where a person is suffering from a stroke mimic, there can also be other symptoms. These will always occur on the other side of the body to the side of the brain in which the stroke has occurred. For example, if the stroke affects the Right Cerebral Artery, then the symptoms will occur on the left side of the body such as the left side of the face, arms or legs.
Early DetectionThe quickest way to determine whether you may be having a stroke is to apply the FAST test described above. For a more definitive diagnosis it is important that you get to the emergency department of your nearest hospital so that you can be reviewed by an emergency physician. If you have suffered a stroke and if you’re being reviewed in a major hospital, you will most likely be examined by a neurologist in the stroke unit.
An emergency physician will use a similar test to the FAST test called the ABCD2 test:
A - If the patient is aged 60 or more, they score 1 point. B - If the patient’s blood pressure is > 140 mmHg systolic and/or > 90 mmHg diastolic, they score 1 point. C - If the patient has clinical features of unilateral weakness, they score 2 points. If the patient has speech impairment without weakness, they score 1 point. D - If the duration of the stroke-like symptoms is > 1hr, they score 2 points. If the duration is < 1hr, they score 1 point. If a patient is a diagnosed Type 1 or Type 2 diabetes sufferer, they score an additional 1 point.
If a patient scores more than 6 points, then they are in a very high risk patient category and will benefit from urgent evaluation and treatment.
If a patient scores less than 3 points, then they may be evaluated as an outpatient if a rapid assessment clinic is available.
If a patient scores more than 3 points but less than 6 points, then they are considered for further treatment and analysis at the discretion of the emergency physician. The emergency physician may admit the patient to the stroke unit for examination by a neurologist.
All stroke patients must undertake the following investigations, which include:
- An Echocardiogram;
- Pathology, including Full Blood Count, ESR and CRP;
- Chest X-Ray; and
- CT Brain within 1 hour of arrival to hospital for early identification of intracerebral haemorrhage and early changes of cerebral ischaemia. A CT perfusion or CT angiogram scan should also be considered unless this is contra-indicated.
Late DiagnosisGenerally speaking, there is no effective treatment for patients who have suffered from a haemorrhagic stroke and treatment is usually confined to preventing a patient’s death. For example, if the haemorrhagic stroke has been caused by an anti-coagulant such as warfarin, then treatment such as Vitamin K administraiton is normally implemented to reverse the effects of the anti-coagulant and reduce the effects of the bleeding.
Where a patient has suffered from an ischaemic stroke, and most people do, then treatment may be available to substantially improve a patient’s outcome. Thrombolysis treatment may be available but must be administered within four and a half hours from the onset of the focal symptoms of the stroke otherwise it will not have any effect. In some high level tertiary hospitals, clot retrieval may also be effective and this can be carried out beyond the four and a half hour window.
Thrombolysis and clot retrieval cannot be administered to all patients who have suffered from an ischaemic stroke. A patient will first need to undergo screening to make sure they are not unsuitable for the type of treatment being considered.
Because there are strict time windows for treatment, particularly thrombolysis treatment, if a patient does not present themselves to the hospital for diagnosis and treatment within that time window, they will lose the opportunity to receive treatment which may substantially improve their outcome. Therefore, if you are at home and you think you have suffered from a stroke, call an ambulance so that you can be transported to the nearest hospital emergency department for the investigations described above.
Medico Legal IssuesIf you, or a member of your family, or a friend, have suffered a stroke and attended your general practitioner or the emergency department of a hospital for diagnosis and treatment and you feel that you have not received appropriate or timely health care, you can lodge a complaint with the Health Service Complaints Agency in your state. In Queensland, the agency is the Office of the Health Ombudsman, in New South Wales, the agency is the NSW Health Care Complaints Commission and in Victoria, the agency is the Health Complaints Commissioner.
The benefit of contacting the Health Complaints Agency in your state is that they will usually investigate your complaint and, in due course, provide you with information about what in their view occurred and whether they believe you received appropriate treatment. They will not make findings of negligence against a practitioner or hospital.
As soon as you reasonably can, which usually means after your period of rehabilitation has finished, you should seek legal advice to ascertain your entitlements to commence a claim for medical negligence and whether time limitations will apply to such a claim.
Some of the more typical factual circumstances we see in a medico-legal stroke claim that may provide a basis for legal action include the following:
- You presented to the emergency department and after investigations, you were discharged whilst you were still suffering from some or all of the stroke symptoms; or
- You presented to the emergency department and after investigations, you were diagnosed with a stroke mimic or a medical condition unrelated to stroke; or
- You presented to the emergency department with classic stroke symptoms and the health practitioners who examined you failed to have you reviewed by a neurologist or to admit you to the stroke unit for further investigation; or
- You presented to the emergency department with classic stroke symptoms and the health practitioners who examined you failed to provide you with appropriate treatment when that treatment was indicated.
Written by Shine Lawyers. Last modified: September 3, 2017.