In the UK around 100,000 people suffer a stroke each year. It remains one of the leading causes of death.
Although someone suffers a stroke every five minutes, an increasing number survive due to early diagnosis and treatment as well as clinical innovations; there are an estimated 1.3 million people in the UK who are stroke survivors.
A patient’s outcome depends on a large number of factors: pre-stroke health status, age, severity of the stroke, availability of treatment, timing of treatment and success of treatment.
The month of May is National Stroke Awareness month and as part of my work supporting people and their families who have had strokes and been treated by the NHS I am sharing what constitutes good clinical practice when diagnosing a stroke and the prescribing of early treatment.
It helps explain what should happen when you, a family member or loved one seeks medical help.
What is stroke?
Stroke is defined as a neurological condition that happens when the blood supply to part of the brain is cut off. This definition often refers to an ischaemic stroke, however there are three types of stroke:
- Ischaemic – occurs when the blood supply to part of the brain is cut off, blocked by a clot which usually originates from either the heart or from within the carotid or vertebral artery.
- Haemorrhagic – occurs when a bleed occurs in or around the brain. The commonest causes of which are a weakened blood vessel, a cerebral aneurysm, an arteriovenous malformation (AVM) or cancer.
- Transient Ischaemic Attack (TIA) – commonly known as a ‘mini-stroke’, however the symptoms are temporary.
Stroke symptoms and signs
It is important to distinguish between a “symptom” and a “sign”. A symptom is what a patient experiences. A sign is what a healthcare professional observes or elicits. The acronym “FAST” captures some, but not all, of the most common symptoms of stroke:
- F – facial weakness
- A – arm weakness
- S – speech problems
- T – time to call 999
Other symptoms include loss of consciousness, inability to swallow, loss of vision and loss of sensation.
Strokes can also cause symptoms such as headache, memory loss or confusion. It may not be possible for a healthcare professional to determine exactly which type of stroke has occurred based on symptoms alone.
Signs that may be elicited by a healthcare professional in patients who have had a stroke include assessment of loss of power in the legs or arms, reduced levels of consciousness, reduced sensation in the legs or arms, facial weakness, or loss of/reduced vision.
How is stroke diagnosed?
Strokes are diagnosed by taking a clinical history, performing a clinical examination, and imaging (scans).
Clinical history: a healthcare professional will talk to the patient and if available, a witness to the patient’s symptoms about: when the symptoms started, what the symptoms were/are and how the symptoms have progressed.
Clinical examination: the National Institute of Health (NIH) stroke scale is a 42-point neurological examination which is used by healthcare professionals to diagnose and evaluate the severity of the stroke.
The neurological examination covers six major areas: loss of consciousness, visual function, motor function, sensation and neglect, cerebellar function, and language.
The table below shows how the NIH stroke scale is used to determine the severity of the stroke.
The National Optimised Stroke Imaging Pathway (NOSIP) provides guidance to hospitals that image patients who present with suspected stroke. The diagram below sets out the pathway that should be followed.
The types of imaging used to diagnose stroke are a CT scan (with or without contrast), enhanced CT angiography or an MRI scan.
The primary form of imaging is CT scan because of:
- Its usefulness in diagnosis.
- The ease of undertaking the scan for patients.
- The availability of CT scanners within hospitals.
Imaging enables doctors to identify the type of stroke, which part of the brain has been affected by the stroke, the severity of the stroke and the cause of the stroke In some patients advanced imaging in the form of CT perfusion scans can be performed.
Of clinical history, clinical examination and imaging, imaging by far is the most accurate and useful way of diagnosing and then planning treatment for a stroke.
If imaging does not show a stroke, then consideration will be given to other causes for the symptoms such as seizures, hemiplegic migraine, or functional stroke.
How are strokes treated?
How a stroke is treated depends upon several factors including:
- The type of stroke
- The severity of the stroke
- When the patient presents to hospital
- The availability of treatment at the presenting hospital
- The patient’s suitability for treatment
There are a number of treatments available for stroke:
Thrombolysis – this involves administering a clot busting drug given intravenously when the stroke is ischaemic and there are no contraindications to this medication. It must be given within 4.5 hours of the onset of symptoms. The drug dissolves the blood clot restoring blood to flow to the brain. Thrombolysis treatment is usually available in most hospitals around the clock.
Thrombectomy – this is used when the stroke is ischaemic, but the clot is large and may not fully dissolve with thrombolysis or where thrombolysis is contraindicated. The procedure involves inserting a catheter into an artery, usually in the groin, and passing a device into the brain which retrieves the clot. If successful, this restores the blood to flow to the brain.
Thrombectomy must be performed within six hours of the onset of symptoms. A hospital’s ability to treat stroke patients with thrombectomy depends upon whether thrombectomy treatment is available in the hospital, the time of day the patient presents to hospital and whether the service is available at that time.
Surgery – If the stroke is haemorrhagic, surgery to open the skull, remove the bleed from the brain and repair any burst blood vessels may be undertaken.
No treatment – there are certain circumstances when no treatment is available for stroke whether it be haemorrhagic or ischaemic. Examples of such scenarios include presenting to hospital too late for treatment, unsuitability of a patient for treatment and lack of availability of treatment.
Professionals involved in diagnosis and treatment of stroke
Patients can present to a variety of healthcare professionals with symptoms of stroke for example general practitioner, ambulance service, out of hours doctors, urgent care centres and emergency departments (A&E).
The treatment of stroke is largely undertaken by Stroke Physicians, Interventional Radiologists and Neurosurgeons.
Outcomes following stroke
Some patients recover fully from a stroke. Some patients are left with either short term, medium term, or long-term problems. Some patients sadly die.
The types of symptoms patients can be left with following a stroke include depression & anxiety, poor memory and concentration, paralysis, difficulty in speaking and understanding, difficulty in reading and writing, problems with swallowing, visual impairment, loss of bladder and bowel control and a change in behaviour.
Stroke Statistics
- Stroke is the leading cause of disability in the UK and two thirds of survivors suffer a disability.
- Stroke is the fourth highest cause of death.
- Stroke affects 1 in 6 men and 1 in 5 women at least once in their lifetime.
- 85% of strokes are ischaemic.
- 12% of patients in England, Wales and Northern Ireland receive IV thrombolysis.
Medical negligence claims
Hudgell Solicitors have successfully represented numerous clients in relation to failures in the diagnosis, treatment, and management of strokes.
In a recent case the family of a man left brain damaged and needing 24-hour care after suffering a stroke received £500,000 damages after a hospital trust admitted delays in diagnosing and treating him.
The man, 48, was taken by ambulance to Pinderfields Hospital in Wakefield, where he underwent a CT scan which showed signs of a basilar artery stroke – a rare form of stroke with a high mortality rate.
The scan was reported as being normal by a radiologist and following that error it was a further three days before an MRI scan was taken, revealing multiple areas of blood tissue death and the artery blockage again.
As part of a legal case led against the Trust by Hudgell Solicitors’ medical negligence specialists it was alleged that, had the CT scan been properly interpreted, the patient would have been diagnosed and received emergency treatment to remove the blood clots within a matter of hours.
Legal representatives of Mid-Yorkshire Hospitals NHS Trust admitted that had the patient been assessed by a consultant in stroke medicine after the initial CT scan, a diagnosis of stroke would have been made.
It also admitted failing to admit the patient to a stroke unit within four hours of arriving at hospital, failing to provide any doctor from the stroke team to examine the patient within a reasonable period of time after his admission and failing to provide a consultant in stroke medicine to assess him following the CT scan.
In another case, our client was awarded damages of £950,000 by another Hospital Trust after doctors ‘missed several obvious opportunities’ to prevent his stroke by failing to prescribe him blood-thinning medication.
Alan Ablett, of Beverley, East Yorkshire, had been worried about his health and went to see his GP.
Following an urgent admission at Hull Royal Infirmary he was diagnosed to have suffered a transient ischaemic attack (TIA), more commonly referred to as a ‘mini stroke’, caused by a temporary disruption in the blood supply to part of the brain.
This should have been a trigger for doctors to place Mr Ablett, 58 at the time, on blood-thinning medication which is effective in preventing strokes.
This didn’t happen and having being discharged home after a week in hospital, he continued to suffer the same symptoms, resulting in him returning to hospital on three consecutive days just over three weeks later.
He was finally admitted again suffering problems with his sight, drooping of his left eyelid and weakness in his left arm and down his left side, having suffered a further stroke.
He was in hospital for a further six days before he was finally given blood thinning medication in the form of Apixaban. In total more than six weeks passed before he was ‘urgently’ started on anticoagulation medication.
Following legal action on Mr Ablett’s behalf by Hudgell Solicitors, Hull University Teaching Hospitals NHS Trust admitted breaching its duty of care.
At Hudgell Solicitors we take all hospital negligence claims seriously, working hard to secure compensation for you and your family.
For many people, making a medical negligence claim against a hospital can be a daunting process, so we’re here to help by offering professional advice and support throughout your claim and will look to offer no win, no fee advice where applicable, you can begin your claim here today.
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