Brain Stem Stroke $40M

The Baltimore Medical Malpractice Lawyer Blog covers verdicts in medical malpractice cases. In this post, I examine a verdict based on failure to respond to symptoms of a brain stem stroke.

In medical malpractice cases, few outcomes are as devastating and illustrative of catastrophic negligence as a missed or misdiagnosed stroke. This is the case of a plaintiff, who suffered a brain stem stroke. He developed locked-in syndrome after a chiropractic neck adjustment. It serves as a profound and tragic example of how a failure of communication and critical assessment in the Emergency Room can alter a life forever.

This blog post examines the medical and legal complexities of this specific type of injury. It highlights the critical signs of a brain stem stroke. The post also discusses the mechanism by which seemingly minor procedures can cause catastrophic damage. It also discusses the life-saving steps an attentive neurologist must take to prevent a permanent disability.

The Catastrophe of Misdiagnosis: A $40M Warning to Emergency Medicine

An appellate court upheld a $40 million medical malpractice verdict against emergency physician. The patient, a 32-year-old, presented to an Emergency Department with urgent symptoms following a chiropractic neck adjustment. Despite presenting with classic warning signs, the patient did not receive the critical care he required. He suffered a massive brain stem stroke that resulted in permanent and catastrophic injuries.

The jury found the doctor guilty of gross negligence. It cited egregious lapses in communication and, critically, his failure to seek a neurological consultation. This verdict reinforces a crucial legal principle. Emergency room physicians are held accountable when their inaction leads to catastrophic, permanent harm.

Recognizing the Warning Signs: Symptoms of a Brain Stem Stroke

A brain stem stroke is particularly dangerous because the brain stem—a half-inch diameter bundle of nerves—controls all basic activities of the central nervous system, including consciousness, blood pressure, and breathing.

A brain stem stroke often presents with a unique and varied set of signs:

• Vertigo and Severe Dizziness: Patients may experience intense dizziness, vertigo (the feeling of spinning). Also, a severe loss of balance (ataxia) or sense of where their body is in space. This feeling of imbalance or unsteadiness often leads to severe nausea and vomiting.
• Vision Changes (The “Eyes” in BE FAST): This can include double vision (diplopia) and involuntary eye movements (nystagmus). Also, an inability for the eyes to move together (dysconjugate gaze).
• Speech and Swallowing Difficulties: Slurred or difficult speech (dysarthria) and trouble swallowing (dysphagia) are common, as the brain stem controls the muscles of the mouth and throat.
• “Crossed Signs”: A hallmark of brain stem lesions is having motor or sensory loss on the same side of the face as the injury, but motor or sensory loss on the opposite side of the body.

For an ER physician, failing to connect these acute, sudden-onset symptoms to the possibility of stroke, particularly in a younger patient following a neck trauma like a chiropractic adjustment, constitutes a severe diagnosis failure.

The Chiropractic Connection: How Neck Adjustment Can Cause Brain Stem Stroke

While a common procedure, cervical spinal manipulation (a chiropractic neck adjustment) carries a small, well-documented risk of causing a stroke, which is what happened in this case. The most likely mechanism for this is not the stroke itself, but an underlying injury to the artery supplying the brain stem.

This process involves:

1. Arterial Injury: The force, rotation, or extension applied during the neck adjustment can cause a tear or dissection in the wall of the vertebral artery (VA). The vertebral artery is particularly susceptible because it passes through the small, bony canals of the upper cervical vertebrae on its way to the base of the skull.
2. Clot Formation: As the artery wall tears, the body attempts to heal itself, which leads to the formation of a blood clot at the site of the injury.
3. Ischemic Stroke: A piece of this clot, called an embolus, can break free and travel up into the brain’s blood supply (the basilar artery), where it lodges in a smaller blood vessel and blocks blood flow to the brain stem. This is an ischemic stroke, and the resulting lack of oxygen causes tissue death and neurological deficits.

It is also important to note that the neck pain and headache that result from the initial artery dissection can occur days or weeks before the actual stroke takes place. Patients often seek chiropractic or medical care for this pain, which means a physician may be presented with a patient whose symptoms are actually the first stage of a catastrophic vascular event.

The Critical Window: A Neurologist’s Response to Prevent Permanent Damage from Brain Stem Stroke

When a patient presents to the ER with symptoms suggestive of a posterior circulation stroke (brain stem or cerebellar), the need for an immediate neurological consult cannot be overstated. A neurologist’s response is governed by the mantra: Time is Brain .

The neurologist’s immediate goal is to restore blood flow and save brain tissue. For an ischemic stroke (the type caused by a clot), the key treatments are highly time-sensitive:

1. Emergency Imaging: A CT scan or MRI is required immediately to confirm the stroke type (ischemic vs. hemorrhagic) and location.
2. Thrombolytic Therapy (Clot-Busting Drugs): If the stroke is ischemic and the patient is within a critical time window (typically 4.5 hours from symptom onset), they may be eligible for an intravenous injection of Tissue Plasminogen Activator (TPA). TPA works to dissolve the blood clot and restore circulation. This significantly improves the chances for a full recovery and reducing long-term disability.
3. Mechanical Thrombectomy (Endovascular Procedure): For large clots, especially those in the major vessels of the brain stem, a neurologist or neurosurgeon may perform a thrombectomy. The doctor inserts a long, thin catheter, typically through an artery in the groin, and guides it to the clot, where they use a specialized device (a stent retriever) to physically remove the clot. This procedure is vital for improving outcomes and must be performed as soon as possible.

Failure to call a neurologist means failing to activate this time-sensitive protocol. This forfeits the patient’s only real chance at preventing permanent, catastrophic damage following a brain stem stroke.

Life Trapped: Understanding Locked-in Syndrome and Patient Care Needs

The ultimate tragic outcome of the misdiagnosis in this case was Locked-in Syndrome (LIS). LIS is a devastating, yet rare, neurological disorder caused by severe damage to the brain stem, most commonly the pons.

• The Condition: LIS results in total paralysis (quadriplegia) of all voluntary muscles. This includes the ability to speak (anarthria), chew, or swallow. Crucially, the individual remains fully conscious, awake, and cognitively intact. They can hear, think, and reason normally, but are trapped within a non-responsive body.
• Communication: The condition typically preserves vertical eye movement and blinking, which becomes the patient’s sole means of communication. They can communicate a “yes” or “no” by blinking or moving the eyes up and down. This system that requires immense patience and skill from both the patient and their care team.

Lifelong Care

A patient with LIS following a brain stem stroke requires comprehensive, lifelong care:

• Medical and Supportive Care: Due to the inability to breathe voluntarily or protect the airway, most LIS patients require an artificial aid for breathing and will have a tracheotomy. Since they cannot safely swallow (dysphagia), they must receive nutrition via a gastrostomy tube (G-tube) inserted directly into the stomach.
• Rehabilitation: They need extensive physical, occupational, and speech therapy. This is vital for preventing secondary complications of immobilization, such as muscle contractures, pneumonia, and pressure injuries (bedsores).
• Assistive Technology: The core of their daily life depends on assistive technology and adaptive equipment. This includes eye-tracking technology that allows them to access computers, communicate by spelling words, and operate other devices.

Recovery of motor function is extremely rare. However, establishing effective communication and providing aggressive supportive care and rehabilitation are essential to maintaining the quality of life and dignity of a patient with Locked-in Syndrome after a brain stem stroke. This verdict stands as a clear signal that the law will hold medical professionals accountable when malpractice strips a patient of their ability to move, speak, and live independently.

You can also read Blog posts about other Verdicts.

Mark Kopec is a top-rated Baltimore medical malpractice lawyer. Contact us at 800-604-0704 to speak directly with Attorney Kopec in a free consultation. The Kopec Law Firm is in Baltimore and helps clients throughout Maryland and Washington, D.C. Thank you for reading the Baltimore Medical Malpractice Lawyer Blog.