He came to the emergency department dizzy and unsteady. The physician diagnosed vertigo, prescribed meclizine for the dizziness, and sent him home. Eight hours later he couldn't walk at all. A CT scan revealed what the ER had missed: a stroke affecting his cerebellum, now too far progressed for the treatment that might have prevented permanent disability.
Stroke is one of the most time-sensitive diagnoses in emergency medicine, and one of the most frequently missed. When emergency departments fail to recognize stroke symptoms, patients lose the narrow window in which treatment can make a difference.
The Diagnostic Challenge
Not all strokes announce themselves with dramatic paralysis and slurred speech. The classic FAST symptoms—Face drooping, Arm weakness, Speech difficulty—represent some strokes well but miss others entirely. Posterior circulation strokes, affecting the brainstem and cerebellum, may present primarily with dizziness, vertigo, and coordination problems. These symptoms mimic benign inner ear conditions that emergency departments see constantly.
The emergency physician facing a dizzy patient confronts a diagnostic dilemma. Most dizziness is benign—viral labyrinthitis, benign positional vertigo, vestibular neuritis. Strokes cause a tiny fraction of dizziness presentations. But that tiny fraction represents a catastrophic diagnosis where missed opportunity means permanent brain damage.
The appropriate response to this dilemma isn't to assume every dizzy patient is having a stroke. It's to systematically evaluate for stroke features that would distinguish dangerous presentations from benign ones, and to maintain suspicion when features don't clearly support a benign diagnosis. When physicians shortcut this process—diagnosing "vertigo" based on the symptom alone without adequately excluding stroke—they set up the tragic misses that malpractice litigation addresses.
The Time Window
Stroke treatment depends on time. The clot-busting medication tPA must be given within 4.5 hours of symptom onset. Beyond that window, the drug doesn't help and risks causing dangerous bleeding. Mechanical thrombectomy—physically removing the clot—extends the window for some strokes, but sooner is always better.
Every minute of stroke means brain damage. The phrase "time is brain" reflects research showing nearly two million neurons die per minute during a stroke. Patients treated within 90 minutes of symptom onset have substantially better outcomes than those treated at three hours. The relationship between time and outcome is steep.
When emergency departments misdiagnose stroke and send patients home, they consume the treatment window while patients wait for symptoms to worsen enough to prompt return. The patient discharged with "vertigo" who returns unable to walk eight hours later has lost the opportunity for tPA. Whatever damage could have been prevented is now permanent.
The Pattern of Misses
Certain stroke presentations are missed more often than others. Posterior circulation strokes—affecting the brainstem and cerebellum rather than the more familiar hemispheric strokes—present with symptoms that overlap substantially with benign conditions. Dizziness, nausea, unsteadiness, and visual changes can all be caused by inner ear problems. But they can also be caused by strokes in the back of the brain.
Younger patients face elevated misdiagnosis risk. Stroke is statistically rare in young adults, leading physicians to anchor on other explanations. The 35-year-old with sudden severe headache gets diagnosed with migraine when she's actually having a hemorrhagic stroke. The 40-year-old with neck pain and dizziness gets told to take ibuprofen when he's actually having a vertebral artery dissection that will cause a massive stroke if untreated.
Transient symptoms create another trap. When symptoms resolve before or during the ED visit, the temptation is to conclude nothing serious happened. But transient ischemic attacks—mini-strokes—are warnings that major strokes may follow. Patients with resolved symptoms who get discharged without workup may have full strokes within days that appropriate intervention could have prevented.
What Evaluation Should Look Like
Patients with possible stroke symptoms need prompt imaging. CT scans can identify bleeding strokes immediately and, with appropriate protocols, can suggest ischemic strokes as well. MRI is more sensitive for early ischemic changes. The choice of imaging depends on clinical circumstances, but some imaging is essential when stroke is a realistic possibility.
Neurological examination should systematically evaluate for deficits that suggest stroke rather than benign causes. Eye movement abnormalities, coordination problems, and subtle weakness may be present even when the patient's main complaint is dizziness. Emergency physicians should know how to look for these findings and what they mean.
When stroke is diagnosed or strongly suspected, treatment should follow rapidly. Door-to-needle time—from arrival to tPA administration—should be under 60 minutes. Delays at any step of this process eat into the treatment window.
Proving Stroke Misdiagnosis
Medical records document what symptoms the patient reported, what examination was performed, what diagnoses were considered, and what workup was done. Comparing this to what the standard of care required reveals where evaluation may have fallen short.
Expert neurologists and emergency physicians can establish whether the presentation warranted stroke evaluation, whether the workup performed was adequate, and whether earlier diagnosis would have enabled treatment that improved the outcome. The causation question is critical: stroke damage that would have occurred regardless of timing isn't attributable to diagnostic delay.
The Stakes
Stroke misdiagnosis often results in permanent, life-altering disability. Patients who could have walked out of the hospital instead leave in wheelchairs, unable to speak, dependent on others for basic care. The damages in these cases reflect the profound impact of preventable brain injury—lost function, lost independence, lost years of normal life. When emergency departments fail to recognize strokes in time, they bear responsibility for the consequences of that failure.