Acute Ischemic Stroke

In Neelands, the plaintiff was a 54-year-old woman who experienced symptoms of arm numbness a day and a half before her speech became garbled, and she fell onto the floor. She was taken to hospital by ambulance where a CT scan showed a right middle cerebral artery stroke. She was not treated with tPA. The expert for the defence noted that stroke specialists were moving away from the “time-based window for thrombolysis” to a “tissue-based window” using multimodal CT or MR imaging to guide decision making. In his view the plaintiff did not suffer the occlusion of the right middle cerebral artery until the time at which she fell to the floor and by the time the CT scan was done 1.5 hours later she had developed irreversible brain damage. Although that seems like a very short time to develop irreversible brain damage, he noted that the plaintiff did not have good collateral circulation which explained why her irreversible brain damage occurred so quickly. He opined that thrombolysis in that situation would have had a high risk of hemorrhage, and would not have been warranted.

In Hasan, the court was presented with medical literature to support the plaintiff’s expert neurologists’ opinion that Mr. Hasan had several unique characteristics that supported the theory that he would have had a successful outcome if treated late on December 3 or early in the morning of December 4. The studies relied on by the defence experts reviewed the likelihood of success of recanalization therapies but did not relate that data to Mr. Hasan’s specific clinical presentation.¹⁸ When a defence expert was confronted on cross-examination with the specific condition of the plaintiff on presentation to the hospital on December 3, he conceded that 73.8% of patients with the plaintiff’s condition would have a good outcome following recanalization therapy.

The use of the medical literature in Hasan underscores the importance of understanding how study data and results are presented, and how your client’s characteristics align with those studies. Data that is presented in terms of overall efficacy in a large cohort of study participants may not be reflective of your client. Working with your experts to ensure you understand the implications of the literature and how it relates to your client’s situation can help you identify strategies to capitalize on, or minimize the impact of, those characteristics.

Conclusion

Certainly not all stroke cases can be won by the plaintiff, even with the most astute plaintiff’s counsel and the best team of expert opinions. But Hasan provides an example of a case where plaintiff’s counsel was able to present a complex case with the help of well-reasoned expert opinions and demonstrative aids. Through meticulous attention to every detail, they were able to unravel the defence opinions on cross-examination and arrive at a winning judgment.

1. Hasan v. Trillium Health Centre Mississauga, 2022 ONSC 3988 (CanLII) at para 155,
   156, 188, 191.
2. Hasan v. Trillium Health Centre Mississauga, supra at para 259.
3. Hasan v. Trillium Health Centre Mississauga, supra at para 153.
4. Hasan v. Trillium Health Centre Mississauga, supra at para 219.
5. Hasan v. Trillium Health Centre Mississauga, supra at para 73, “see Marchand, at paras. 60-61.”
6. Hasan v. Trillium Health Centre Mississauga, supra at para 115, 252.
7. Hasan v. Trillium Health Centre Mississauga, supra at para 222.
8. Hasan v. Trillium Health Centre Mississauga, supra at para 224.
9. Hasan v. Trillium Health Centre Mississauga, supra at para 213.
10. Hasan v. Trillium Health Centre Mississauga, supra at para 227.
11. Hasan v. Trillium Health Centre Mississauga, supra at para 225.
12. Hasan v. Trillium Health Centre Mississauga, supra at para 229.
13. Hasan v. Trillium Health Centre Mississauga, supra at para 240.
14. Hasan v. Trillium Health Centre Mississauga, supra, see paras 70, 71 for a description
    of the factors to be considered.
15. In this case, Rosen’s Emergency Medicine, (7th edition).
16. Hasan v. Trillium Health Centre Mississauga, supra at para 110, 112, 114.
17. Journal of Stroke and Cerebrovascular Diseases, Vol. 27, No. 8 (August), 2018; pp
    2214-2227.
18. Hasan v. Trillium Health Centre Mississauga, supra at para 297.