Stroke negligence claims frequently involve difficult questions around diagnosis, timing and causation. A delay does not automatically mean that the outcome would have been different; the key issue is often whether earlier recognition or treatment would, on the balance of probabilities, have materially altered the patient’s neurological outcome.

Watch the full webinar with Dr Kayvan Khadjooi here >

Stroke Diagnosis: Why Clinical History Matters

Stroke is primarily a clinical diagnosis.

During the webinar, Dr Khadjooi emphasised the importance of returning to the fundamentals: obtaining a detailed history, carrying out a neurological examination and then using investigations to support or clarify the diagnosis.

Typical stroke symptoms are sudden in onset and involve focal loss of neurological function. These can include:

• unilateral facial, arm or leg weakness;
• difficulty speaking or understanding language;
• visual field disturbance or double vision;
• impaired coordination; and
• significant problems with balance.

The distinction between “negative” neurological symptoms, such as loss of power, and “positive” symptoms, such as tingling, flashing lights or limb shaking, can also assist with the differential diagnosis.

The National Institutes of Health Stroke Scale, or NIHSS, provides a standardised way of recording neurological deficit. However, Dr Khadjooi cautioned that the numerical score does not always reflect the functional significance of the deficit.

For example, mild expressive dysphasia may generate a relatively low score while still being profoundly disabling for someone whose profession depends upon speech. Similarly, isolated weakness affecting the dominant hand may have major consequences for someone whose occupation relies on fine motor control.

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“Stroke is a clinical diagnosis.”

That principle can be particularly important in claims where an early CT scan was normal.

Dr Khadjooi explained that an acute CT may initially show no visible infarction. In appropriate circumstances, that can be a positive finding because it may indicate that irreversible damage has not yet developed.

Accordingly, a normal early CT does not in itself exclude an ischaemic stroke.

Misdiagnosis and Stroke Mimics

One of the principal challenges in stroke medicine is that several other conditions can produce similar neurological symptoms.

Dr Khadjooi identified migraine as a particularly common stroke mimic. Other differential diagnoses can include seizure, hypoglycaemia, subdural haematoma, multiple sclerosis, brain tumour, syncope, inner-ear disorders, sepsis and functional neurological symptoms.

This makes careful history-taking particularly important.

During the webinar, Dr Khadjooi discussed a patient referred with recurrent episodes involving loss of control of one hand. More detailed questioning identified episodes of jerking, rather than simple weakness. Imaging subsequently revealed a brain tumour causing seizure activity.

For medico-legal purposes, the relevant question may therefore extend beyond whether stroke was ultimately diagnosed. It may be necessary to consider whether the presenting features were appropriately explored and whether reasonable differential diagnoses were considered.

Hyper-Acute Stroke Treatment and the Importance of Time

The central concept behind hyper-acute ischaemic stroke treatment is the distinction between irreversibly damaged brain tissue and the surrounding area of tissue that remains at risk but potentially salvageable.

Dr Khadjooi described this threatened tissue as the ischaemic penumbra.

If blood flow can be re-established quickly enough, part of the penumbra may be preserved. As the period of ischaemia continues, however, more tissue can become permanently infarcted.

This is why delay is so significant in potential stroke negligence claims.

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“The sooner we can re-establish the blood flow to this area, then the penumbra can be saved.”

Two major treatments were discussed during the webinar: intravenous thrombolysis and mechanical thrombectomy.

Thrombolysis

Thrombolysis uses clot-dissolving medication in eligible patients with acute ischaemic stroke.

Dr Khadjooi explained that treatment is not appropriate simply because a patient arrives within the relevant time window. The clinical team must also consider matters including:

• whether the clinical presentation is consistent with stroke;
• whether the neurological deficit is disabling;
• whether symptoms are rapidly resolving;
• the known time of symptom onset;
• anticoagulant medication or clotting disorders;
• blood pressure;
• imaging findings; and
• other contraindications, including recent surgery.

For medico-legal cases, Dr Khadjooi highlighted the first three hours after symptom onset as particularly important when considering whether earlier thrombolysis could probably have produced a better outcome.

The assessment must therefore be patient-specific rather than based purely on the theoretical availability of thrombolysis.

Mechanical Thrombectomy and Missed Treatment Opportunities

Mechanical thrombectomy involves physically removing a clot from a major cerebral artery.

Unlike thrombolysis, it is suitable only for a relatively small group of stroke patients, including those with an appropriate large-vessel occlusion.

Dr Khadjooi explained that factors such as the patient's neurological deficit, pre-stroke functional status, vessel involved, imaging and timing all influence eligibility.

Where a clinical negligence claim alleges that thrombectomy was missed, an expert may therefore need to reconstruct the likely clinical pathway carefully.

Questions may include:

• When did symptoms begin?
• When should stroke reasonably have been suspected?
• When could imaging have been performed?
• Would a relevant large-vessel occlusion have been identified?
• Was the patient otherwise eligible for thrombectomy?
• Could transfer to an appropriate centre realistically have taken place within the necessary timeframe?

Dr Khadjooi stressed during the Q&A that experts should consider how stroke services work in real clinical practice, including the time required to transfer patients between hospitals.

Missed TIA and Subsequent Stroke

Transient ischaemic attacks can create particularly important questions around preventative treatment.

Dr Khadjooi presented a case involving a 54-year-old man with a history of migraine but also significant vascular risk factors. He experienced sudden left arm weakness and slurred speech that resolved completely. His CT was normal and the episode was attributed to migraine.

Five days later, he returned with a stroke.

Dr Khadjooi's opinion in the example was that the original presentation should have led to a suspected TIA diagnosis, aspirin treatment and urgent TIA assessment.

This illustrates an important medico-legal distinction: a plausible alternative diagnosis does not necessarily remove the need to consider stroke or TIA where the history contains sudden focal neurological symptoms and relevant risk factors.

The subsequent causation analysis then requires consideration of whether appropriate preventative treatment would probably have avoided the later stroke.

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“The sooner the better.”

In the webinar Q&A, Dr Khadjooi explained that although assessment within 24 hours is the ideal, real-world service pressures may affect when a patient can actually be reviewed.

The medico-legal significance of delay therefore depends on the individual facts — particularly whether a further stroke occurred during the period in which assessment or treatment was delayed.

Posterior Circulation Stroke: A Diagnostic Challenge

Posterior circulation strokes can be particularly difficult to identify.

Symptoms may include nausea, dizziness, vertigo, visual disturbance and problems with balance. These can initially appear less characteristic of stroke than obvious unilateral weakness or speech disturbance.

Dr Khadjooi presented a case involving a 46-year-old man with paroxysmal atrial fibrillation who presented with headache, vomiting, unsteadiness and an episode of double vision. Although he initially appeared better, he remained unable to walk and subsequently developed altered consciousness.

Later imaging demonstrated a basilar artery thrombus and extensive infarction of the pons.

The case illustrates why ongoing neurological symptoms and deterioration should be considered carefully even where the initial presentation is non-specific.

For solicitors reviewing a similar claim, relevant records may include nursing observations, neurological examinations, escalation decisions, imaging requests and the timing of medical review.

Hypertension and Stroke Causation

Hypertension was another recurring theme within Dr Khadjooi's presentation.

He described it as a major risk factor for both ischaemic and haemorrhagic stroke. However, establishing that a patient's blood pressure was poorly managed is only part of the analysis.

The expert must also consider whether hypertension was causally relevant to the particular type of stroke experienced.

Dr Khadjooi highlighted claims involving:

• failure to investigate raised blood pressure;
• failure to diagnose hypertension;
• inadequate monitoring after diagnosis; and
• failure to respond where medication or another treatment increased blood pressure.

The precise mechanism of the eventual stroke matters.

He explained that a causal relationship may be easier to evaluate in certain stroke mechanisms, such as lacunar stroke, than in others.

There are also practical considerations. Patient compliance, opportunities for follow-up and the realities of primary-care monitoring may all need to be taken into account.

Atrial Fibrillation and Preventable Stroke

Atrial fibrillation is another important area in stroke litigation because of its association with embolic stroke.

Dr Khadjooi discussed several recurring scenarios:

1. anticoagulation was not commenced despite a risk profile indicating that it should have been considered;
2. a patient's stroke-risk profile changed but was not reassessed; or
3. anticoagulant medication was withheld for too long before a surgical procedure.

Risk stratification is therefore central to these claims.

When considering a stroke in a patient with atrial fibrillation, Dr Khadjooi emphasised that it should not simply be assumed that AF caused the event. The mechanism of the stroke must first be established.

If AF was relevant, the expert can then consider whether the patient's risk was assessed appropriately and whether anticoagulation was commenced, monitored and managed in accordance with the circumstances at the time.

Medico-Legal Considerations

Across the case examples discussed during the webinar, a common theme emerges: the existence of a delay is only the start of the medico-legal analysis.

For a claim involving missed or delayed stroke treatment, the records may need to establish several separate stages:

Breach

Was stroke or TIA reasonably identifiable at the time?

Were important neurological symptoms appropriately investigated?

Was deterioration recognised and escalated?

Were relevant risk factors appropriately managed?

Treatment opportunity

If the breach had not occurred, what treatment could realistically have been delivered?

Was the patient eligible for thrombolysis, thrombectomy, aspirin, anticoagulation or another preventative intervention?

Causation

Would that treatment probably have changed the eventual outcome?

What was the patient's neurological status at the relevant point?

What did contemporaneous imaging show?

How much time had elapsed from symptom onset?

Were there contraindications or other clinical factors affecting treatment?

These distinctions are especially important in stroke litigation because treatment effectiveness changes rapidly over time and not every patient who suffers a delay would otherwise have been eligible for intervention.

Case Examples & Outcomes

The webinar used several practical case studies to demonstrate where potential claims can arise.

Missed TIA

A patient with sudden, resolving neurological symptoms was diagnosed with migraine and later suffered a stroke.

The medico-legal issues included recognition of the original TIA, early aspirin treatment and whether the later stroke could probably have been prevented.

Delayed Posterior Circulation Stroke Diagnosis

A patient with headache, vomiting, visual disturbance and severe unsteadiness later deteriorated and was found to have a basilar artery thrombus.

The issues included triage, ongoing neurological symptoms, escalation and whether an opportunity for thrombolysis or thrombectomy had been lost.

Undiagnosed or Poorly Controlled Hypertension

Dr Khadjooi discussed claims in which raised blood pressure was either not followed up or was inadequately monitored, followed by a stroke whose mechanism was considered consistent with hypertension.

Failure to Anticoagulate Atrial Fibrillation

Other examples concerned patients whose stroke-risk scores had not been assessed or reassessed, resulting in anticoagulation not being offered before a subsequent embolic stroke.

Key Takeaways for Solicitors

When reviewing a potential stroke negligence claim, the chronology is often critical.

Particular attention should be paid to the exact onset of symptoms, neurological observations, timing of medical reviews, imaging, vascular risk factors and the point at which treatment could realistically have taken place.

It is also important not to equate missed diagnosis automatically with avoidable injury.

A stroke expert may need to address two distinct questions: whether the care fell below an acceptable standard and whether different care would probably have led to a materially better outcome.

Dr Khadjooi's webinar demonstrates why those questions often require detailed specialist analysis of the records, imaging, treatment criteria and real-world clinical pathway.

The Value of a Practising Stroke Expert

During the webinar Q&A, Dr Khadjooi was asked what makes an expert particularly valuable to solicitors.

He highlighted the importance of remaining in active clinical practice, staying up to date and understanding how treatment pathways operate in reality.

That includes recognising practical issues such as transfer times between hospitals and whether a particular investigation would genuinely have been available when the patient presented.

He also stressed the importance of neutrality and the expert's overriding role in assisting the court.

For solicitors handling complex stroke claims, that combination of current clinical practice and medico-legal experience can help distinguish a theoretical missed opportunity from one that could genuinely have altered the patient's outcome.

Watch the Full Webinar

Hear Dr Kayvan Khadjooi discuss stroke diagnosis, treatment delays, causation and real medico-legal case examples in full.

Watch the full webinar here >