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VA Delay in Diagnosis of TIA/Stroke

$950,000 – Medical Malpractice/Negligence


Veterans Administration doctors failed to recognize signs of transient ischemic attack and stroke which required emergent workup and treatment. A 50-year-old had massive stroke.

On February 20th, 50-year-old Mr. S went to the Palo Alto VA Medical Center emergency room with complaints of “my heart beating in my ears,” right-sided visual disturbance, headache, jaw clenching, and neck pain. He was sent home with Discharge Instructions noting a final diagnosis of acute sinusitis and otitis media (ear infection).

Later that morning, Mr. S saw an ophthalmologist with right eye complaints, including light sensitivity, blurriness and haziness like a film was over his eye and mild, right-sided headache. Mr. S was counseled on ocular migraines.

Three days later, Mr. S was seen by VA Internal Medicine Physician David Yao, M.D., for follow-up. Mr. S complained that he was unable to sleep much because when he lies down, he feels his heart pounding. Mr. S was sent home with pseudoephedrine and sinus wash. On February 26th Mr. S tried to stand and fainted.

On the following day, February 27th, Mr. S experienced left-sided facial numbness, uncontrolled clenching of his left hand, and some weakness and skin irritation in his left leg. He went to the Palo Alto VA Medical Center emergency room and saw Dr. James Connor. In addition to the recent left face, arm, and leg weakness and numbness, he also was complaining of a headache and dizziness. Dr. Connor’s report noted a differential diagnosis of possible CVA (cerebral vascular accident/stroke) vs. TIA. Dr. Connor said he discussed the case with a neurologist who felt TIA was unlikely. There is no record of the phone conversation and the government could not identify the neurologist who spoke to Dr. Connor. A non-contrast CT of the head was performed and was normal, but no MRI or other diagnostic radiograph or ultrasound was taken to rule out a CVA or TIA or its cause.

Dr. Connor’s ED report indicated that he “will recommend 1 ASA (aspirin) per day.” However, Mr. S and his wife both state they did not receive any instructions or counseling for Mr. S to take aspirin. The discharge instructions he received gave a final diagnosis of sinusitis and instructed the patient to see his primary care physician as soon as possible.

On March 1st, Mr. S began having increased problems with his memory. Mr. S contacted the V.A. Advice Nurse and was advised to return to the emergency room. Nurse Pless advised Mr. S to see a doctor now or his condition could worsen, and to take ASA (aspirin) as directed.

Mr. S went to the emergency room of the VA Medical Center in Palo Alto on March 1st, and was seen by Dr. Sanjiv Singh. There is no reference to aspirin in his active medication list. On physical exam, Mr. S did exhibit confusion with word choice, misdated some forms, and initially responded that he had no siblings when he had four. A CT showed multifocal hypodensities, and Dr. Singh noted a need for MRI/MRA of the head and neck for further evaluation. The neurology resident noted that they “remained concerned for stroke.” No CTA (CT Angiogram) or carotid duplex was ordered and an MRI/MRA was not scheduled until the next day. Mr. S received no anticoagulation or antiplatelet therapy.

Mr. S was taken for an MRI that afternoon. It revealed acute bilateral watershed infarcts and right carotid occlusion suggestive of right carotid dissection. While in the waiting area after his MRI was completed, Mr. S became unresponsive and suffered a massive stroke. A Code Blue was called and ultimately it was decided to initiate IV tPA, a stroke treatment that has the potential of reversing stroke effects.

Following the stroke, Mr. S was noted to be perfusion dependent and suffered an escalation of symptoms when his head was elevated at times.


If appropriate studies had been ordered within the standard 48-hour window, then the carotid dissections would have been identified, along with the fact Mr. S had hypoperfusion. If Mr. S had been properly managed, more likely than not the massive stroke suffered on March 2 would have been avoided and he would have resumed his normal life.

Defendant claimed that the physicians at the VA acted within the standard of care at all times and that Mr. S was advised to take aspirin on February 27, even though defendants conceded that aspirin is only effective in preventing strokes in 1 out 5 of patients with TIA and that more likely than not the stroke would not have been prevented by aspirin therapy.

Special Notes

Plaintiff demanded $2,367,061 to resolve the matter, which was rejected by defendant. At mediation, defendant offered $100,000. The case was set to be tried. In the interim, the Court instructed counsel to attend another mediation session, at which time the case resolved for $950,000 shortly before trial.




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