Most people trust the doctors in emergency rooms to recognize a stroke. But what happens when there is a misdiagnosis? Research shows that emergency physicians are most likely to miss a stroke when the patient’s main complaint is dizziness or headache rather than weakness or slurred speech, and when the patient is younger, female, or a member of a minority group. A stroke that is mistaken for a migraine or an inner ear problem can mean a patient is sent home during the hours when treatment works best.
At Davis & Davis, our Houston medical malpractice attorneys represent patients and families harmed by missed and delayed stroke diagnoses. This article looks specifically at the emergency room setting: what the research says about who is most at risk of a missed stroke, why certain symptoms are overlooked, how the timing of treatment affects outcomes, and the special Texas rules that apply to claims involving emergency care.
What the Johns Hopkins Research Found
A 2014 study led by Johns Hopkins neurologist David Newman-Toker, published in the journal Diagnosis, examined hospital records from nine states. As summarized in the Johns Hopkins announcement of the study, researchers estimated that up to 12.7 percent of patients later admitted for stroke had been seen in an emergency department in the previous 30 days and sent home with a possible misdiagnosis.
The risk was not evenly distributed. Women were reported to be about 33 percent more likely than men to have a stroke missed, minorities were about 20 to 30 percent more likely, and younger patients were nearly seven times more likely to be misdiagnosed than older patients. Patients whose strokes were missed often came in with dizziness or headache and left with a benign diagnosis such as an inner ear infection or migraine, or with no diagnosis at all.
The study did not establish why these gaps exist. The researchers suggested possible factors, including communication barriers and the assumption that stroke is a disease of older adults.
Why Dizziness and Headache Strokes Are Missed
The classic stroke warning signs, such as facial droop, arm weakness, and speech difficulty, come from strokes in the front part of the brain. Strokes in the back of the brain, which affect the brainstem and cerebellum, can instead cause vertigo, imbalance, nausea, double vision, or a severe headache. Those symptoms overlap with common, harmless conditions, so they are easy to dismiss.
Limits of an Early CT Scan
A CT scan is good at detecting bleeding in the brain, but in the first hours it often cannot show an ischemic stroke, especially one in the back of the brain. A normal CT does not rule out stroke. MRI is far more sensitive, and when the clinical picture is unclear, the decision to order one, or to consult neurology, can be critical.
The Bedside Exam
For patients with sudden, continuous dizziness, emergency physicians can use a structured eye movement and gait examination, often called HINTS, to help separate an inner ear problem from a stroke. When that type of exam is skipped or performed incompletely, the chance of sending a stroke patient home rises.
A 2022 federal review of diagnostic errors in emergency departments, prepared for the Agency for Healthcare Research and Quality by a Johns Hopkins team, identified stroke as one of five conditions that account for a large share of serious harm from emergency misdiagnosis and found that strokes were missed far more often when dizziness was the main symptom than when weakness was.
Why Every Hour Matters in Stroke Treatment
Treatment for ischemic stroke is time-dependent. Clot-dissolving medication is generally given within about 4.5 hours of when symptoms began, and mechanical clot removal can be offered to selected patients with large vessel blockages up to 24 hours after onset. A patient who is sent home with a migraine diagnosis may lose access to both options.
Timing matters even when the first event is a transient ischemic attack or a minor stroke. In the Oxford EXPRESS study published in The Lancet in 2007, urgent assessment and treatment after a TIA or minor stroke reduced the risk of a recurrent stroke over the next 90 days by about 80 percent compared with slower follow-up care. Our article on what happens when a TIA is misdiagnosed discusses those warning events in more detail.
When a Missed Stroke May Be Malpractice in Texas
Not every missed stroke is malpractice. Some strokes present so atypically that even a careful physician could not have recognized them. A claim generally requires showing that the provider fell below the accepted standard of care, for example by failing to perform an adequate neurological exam, relying on a normal CT to rule out stroke, or not consulting neurology when the presentation called for it, and that this failure caused harm.
Texas law adds two important hurdles in emergency room stroke cases. First, under Section 74.153 of the Texas Civil Practice and Remedies Code, a claim based on emergency medical care in a hospital emergency department generally requires proof that the provider acted with willful and wanton negligence, a higher standard than ordinary negligence. Second, Texas does not allow recovery for a lost chance of a better outcome below 50 percent, so a patient must show that timely diagnosis and treatment more likely than not would have led to a better result. These rules make careful medical review especially important in emergency cases. More information on missed vascular emergencies is available on our heart attack and stroke misdiagnosis page and our emergency room errors page.
Other Chapter 74 rules also apply: written notice to each provider at least 60 days before suit, a report from a qualified medical professional served within 120 days after each defendant answers, a general two-year filing deadline with a 10-year statute of repose, and a $250,000 cap on noneconomic damages per claimant against physicians and individual providers combined.
Talk With Davis & Davis About a Missed Stroke
Our firm focuses on medical malpractice, and we work with qualified medical professionals, including neurologists and emergency physicians, to reconstruct what was known at each point in an emergency visit and whether the response met the standard of care. Every case is different, and we cannot promise a particular result.
If you or a family member was sent home from an emergency room and later diagnosed with a stroke, contact Davis & Davis to request a free consultation.
Source: NPR.org, “Emergency docs more likely to miss signs of stroke in the young“, Linda Poon, Accessed Sept. 22 2014
Frequently Asked Questions About Missed Strokes in the Emergency Room
Can a stroke be mistaken for vertigo or a migraine?
Yes. Strokes in the back of the brain can cause dizziness, imbalance, nausea, or a sudden severe headache rather than the classic arm weakness or facial droop. Research has found that strokes presenting this way are among the most likely to be missed in the emergency room.
Does a normal CT scan rule out a stroke?
No. A CT scan is useful for detecting bleeding, but it often does not show an ischemic stroke in the first hours, particularly in the back of the brain. MRI is more sensitive, and a careful neurological exam remains important even when the CT is normal.
Who is most likely to have a stroke missed in the ER?
A Johns Hopkins study found that younger patients, women, and minority patients were more likely to be sent home with a missed stroke, along with patients whose main symptoms were dizziness or headache. Younger patients were nearly seven times more likely to be misdiagnosed than older patients.
Is it harder to sue over emergency room care in Texas?
Often, yes. For emergency medical care provided in a hospital emergency department, Texas law generally requires proof of willful and wanton negligence rather than ordinary negligence. That higher standard makes a detailed review of the records and the timeline especially important.
How long do I have to file a claim for a missed stroke in Texas?
Texas generally allows two years for a health care liability claim, with a 10-year statute of repose as an outer limit. Written notice must be sent at least 60 days before a lawsuit is filed, so it is wise to speak with an attorney well before the deadline.
