APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER:
20230051
OBJECTING PARTY:
worker, self-represented
RESPONDENT:
employer
HEARING:
videoconference hearing, January 4, 2023
HEARD by: l. diaz, appeals resolution officer
ISSUE
The worker objects to the Adjudicator’s August 19, 2022 decision which denied initial entitlement to a vertebral artery dissection leading to a stroke under the claim.
BACKGROUND
On February 11, 2022, while employed as a Casual Repairman, the worker attended a call at X Hospital to repair a radiator that had a heating issue. Two days later, the worker attended the hospital emergency department with symptoms of nausea, vomiting, and right-sided facial pain. Several days later, following their third visit to the hospital, the worker then learned they had sustained a vertebral artery dissection which led to a stroke. The worker subsequently claimed that bumping their head and neck on multiple occasions at work on February 11, 2022 is what led to the vertebral artery dissection and the eventual stroke.
Adjudicator’s decision
Further to the August 19, 2022 decision, the Adjudicator concluded that the medical evidence did not support a head injury on February 11, 2022 related to the worker performing their regular job duties, and as a result, denied entitlement to an occupationally related stroke under the claim.
Worker’s position
The worker maintained that they had in fact bumped their head on numerous occasions while attempting to repair the radiator on the date in question. It was their position that performing their regular job duties on February 11, 2022 while repairing the radiator is what led to the vertebral artery dissection and eventual stroke.
AUTHORITY
- Operational Policy Manual Published
11-01-01, Adjudicative Process November 3, 2008
15-02-01, Definition of an Accident October 12, 2004
- Workplace Safety and Insurance Act (WSIAT), 1997
Section 13(1), (2)
ADDITIONAL REFERENCES
Medical opinion by Dr. Kertesz, Neurologist, documented in Workplace Safety and Insurance Appeal Tribunal (WSIAT) decision 1824/21
ANALYSIS
I find the worker does not have initial entitlement to a vertebral artery dissection leading to a stroke under the claim. In arriving at this decision, I had regard for the worker’s testimony and arguments, the relevant file information, and the applicable legislation and policy.
The worker testified that they sustained a chronic dissection of their artery which resulted in a stroke, and that their stroke was caused by the work activities they performed on February 11, 2022. The worker confirmed that they were also a part-time Maintenance Person, and a Casual Health Care Aide, though they rarely performed work as an Aide – they recall the last time they performed work in this field was in December 2021.
The worker advised that on February 11, 2022 they were notified by the Station Engineer that there was a drop in the temperature at X Hospital, and that they were losing heat. They attended X Hospital at 12:00 pm along with several other individuals. They advised that the radiator was frozen and cracked and that the unit was down. The worker’s direct supervisor was present, along with a fellow co-worker ‘Z’, and a contractor ‘M’. The worker, the co-worker, and the contractor all physically worked at the hospital to restore heat, and the other two individuals were present in a supervisory capacity.
The worker reported that they, the co-worker, and the contractor worked until 8:00 pm to attempt to figure out where the leaks in the radiator were, and to fix them. The worker described that the working space was tight – the maintenance room was located in a 10’ by 15’ concrete room, and there was only 1’ of space to access the unit, which was a 5’ by 5’ unit. They indicated there were 16” of space on the right side, and only 4” within which to walk. The worker advised that all the pipes were located on the left side, which led to the radiator. On the other side, there were pumps, valves, water lines, electrical panels, air movers, etc. Overall, the worker reported there was extremely limited space within which to move.
From 12:00 pm to 8:00 pm on that day, the worker indicated they would often be on their knees to access the unit, had to crawl, had to fit into various cubby holes, and was in various precarious positions. As a result of the limited space, the worker reported bumping their head, neck, and body on numerous occasions. Despite this, the worker confirmed they did not sustain any contusions or cuts, but they did bump their head and hurt their neck.
At the end of the day, the worker reported they had fixed several leaks on the radiator which permitted the hospital to use it on a temporary basis, however, a new radiator still had to be ordered.
The worker re-confirmed they had worked at X Hospital from 12:00 pm until 8:00 pm. They then went home and to bed. At 8:00 am the next day, they stated they were called once again to X Hospital to work on a fire panel until 12:00 pm. They stated they then went home and went to bed as they were still tired from the previous day, and their body was still hurting. At 4:00 pm they received a call to repair a heating system, which they worked on for approximately 1.5 hours. After doing so, they then went home and went to bed once again.
On Sunday February 13, 2022, the worker reported that their spouse called the hospital as they couldn’t walk properly, couldn’t see properly, had balance issues, and their head and neck were hurting. The ambulance came to transport them to the hospital. When the worker was seen at the hospital, they were informed by the treating physician that they had the Norwalk virus and was discharged. The worker returned home and stayed in bed – they recall watching/listening to the Super Bowl.
On February 14, 2022, the worker was once again transported to hospital by ambulance as their symptoms had worsened. The worker was examined at the hospital and was told that they had an ear infection, for which antibiotics were prescribed. The worker was then once again sent home and was told that if their symptoms did not improve, to return to hospital emergency in two days. They had to wheel them out to their car from hospital emergency on February 14, 2022 as they were unable to walk. When they arrived home, the worker reported that they fell out of their vehicle as they couldn’t walk – their spouse had to help them back to bed.
Finally, on February 16, 2022, an ambulance was once again called. At the hospital, the worker insisted that they would not leave until they did further investigations and found out what was wrong, as they couldn’t walk. They performed a CT scan on the worker, which did not initially show anything. The worker was informed they had a sinus infection. The worker reported passing out while in hospital. A CT with angiogram was then performed which confirmed the worker had sustained a stroke. They then arranged to have the worker flown to City T for further treatment and assessment. The worker reported being admitted to hospital in City T from February 18 until February 28, 2022, following which they were sent to Y Hospital. At the hospital, the worker was told that it was ‘WSIB’ related.
The worker confirmed that they are still in physiotherapy. They advised that they have had to learn how to walk again and still has difficulty walking. They indicated that the process has been very difficult and that they appreciated the opportunity to tell their side of what had happened.
Review of relevant medical reports
Although all file medical reports were reviewed, only the most pertinent medical reports are referenced below in relation to the issue in dispute.
The worker underwent assessment at L Hospital on February 16, 2022 by Dr. Visser. The hospital report confirmed it was the worker’s third visit to the Emergency Department (ED) by ambulance. The worker described nausea and vomiting occurring on February 13, 2022. They were seen in the ED on that date and was thought to have a viral infection and was sent home. They returned for a second visit on February 14, 2022 at which point it was thought the worker might have mastoiditis. As there was no imaging available that evening, they were sent home. They presented to the ED on February 16, 2022 with persistent right-sided facial pain, which was described as a temporal type headache, radiating into their ear, below their eyeball and into the right side of their face. There was no rash. The worker denied any associated neck pain or neck stiffness. The worker complained of a 10/10 headache, associated with the lateral aspect of their ear and into the temporal artery of their head. The worker also reported double vision that they believe started on February 14, 2022. The worker described seeing two images where the right side seemed to be slightly over the left and a bit of a visual field defect on the right side as well. The worker was oriented and had full range of motion of their neck. They were tender to palpation over their right mastoid as well as over their temporal aspect and around their eye.
Dr. Visser also reviewed their CT and indicated it was unremarkable, with no change compared to the last one performed in September 2021.
On February 18, 2022, the worker underwent a 3D CT scan which confirmed abnormal appearance of the proximal segment of the right vertebral artery, which was concerning for a vertebral artery dissection. There was no acute intracranial process noted.
The worker underwent assessment by Dr. Basir on February 18, 2022. The worker described their symptoms beginning on February 13, 2022 when they developed a headache with associated nausea, vomiting, diarrhea, and balance issues. By February 16, 2022, the worker’s symptoms had worsened, with increasing dizziness and new onset double vision, and numbness in their right face and arm. The worker described vertical diplopia, and significant pain on the right side of the head and face. The worker’s medical history was significant for diabetes, hypertension, diabetic neuropathy; smoking 6 cigarettes per day, and occasional alcohol intake. Family history was significant for stroke as their father died at the age of 68 due to stroke. In summary, Dr. Basir confirmed the worker had a right vertebral artery dissection, and that they had likely suffered a brainstem or cerebellar stroke. An MRI was requested.
On February 18, 2022, Dr. Sweet completed a Mild Traumatic Brain Injury (MTBI) initial assessment report, and documented the following accident history: “Pt was working in tight spaces, twisting neck & lifting injury to vertebral artery – stroke”. Page 2 of this report confirmed there was no concussion/head injury. The Health Professional’s Report completed by Dr. Sweet on this date confirmed the diagnosis of ‘vertebral artery dissection, brain stem stroke’. It was noted the worker remained in hospital in City T, and would be undergoing physiotherapy and occupational therapy.
The worker underwent a 3D CT of the head on February 19, 2022, with the clinical history of ‘stroke syncope with movement of head’, which provided the following impression:
There is evidence of T1 hyperintense thrombus within the right V2 segment vertebral artery. The superior extent appears to have progressed from the CT angiogram and may now involve the proximal right V3 segment artery. This is most compatible with a vertebral artery dissection. The V4 segment arteries and basilar artery appear patent. There is no abnormality of the circle of Willis or posterior cerebral arteries.
There are areas of subacute infarction involving the right dorsal lateral medulla and adjacent
superior cerebellar vermis.
A February 21, 2022 CT scan confirmed the impression of “Established infarct within the right dorsal lateral medulla and adjacent right inferomedial cerebellum”. There was no evidence of any significant mass effect or hemorrhagic transformation and no new areas of infarction.
On February 21, 2022, the worker underwent assessment by Dr. Guzman, who essentially reiterated the worker’s history of present illness, social history, past medical, and impression that the worker had had a vertebral artery dissection and subacute cerebellar and right dorsolateral medullary infarction. It was noted that the worker’s diabetes had not been well-controlled.
I also had regard for Dr. Migay’s March 25, 2022 report. The accident history documented in this report is slightly different from prior reports submitted to file. The worker reported to Dr. Migay that they were working at Health Care in Maintenance on February 13, 2022 and that they hit their head twice, once under the furnace and then again inside the furnace unit. They then presented to hospital emergency with headache and nausea and was discharged home. All subsequent information documented by Dr. Migay in terms of the worker’s treatment in hospital was similar to prior reports. On examination, the worker was able to stand on their own, however they could not balance on either foot alone, and they could not tandem walk. They had decreased sensation on the right facial nerve and hearing impairment on the left side. The worker could not discriminate sharp from dull touch in the left upper extremity, and could not discriminate sharp from light touch bilaterally in the lower extremities. Impression was that the worker had had a significant event in terms of a right vertebral artery dissection in addition to infarcts of the right dorsal lateral medulla and adjacent superior cerebellar vermis. He had ongoing sensory abnormalities in addition to the difficulty with their vision. He also had problems with balance as indicated by their inability to stand on one foot or tandem walk.
Analysis
Policy 11-01-01, Adjudicative Process, records the following in part:
All decision-makers use the same criteria for ruling on initial entitlement to WSIB benefits. This system is known as the "five point check system."
An allowable claim must have the following five points
an employer (see 12-01-01, Who is an Employer?)
a worker (see 12-02-01, Workers and Independent Operators)
personal work-related injury
proof of accident, and
compatibility of diagnosis to accident or disablement history.
Policy 15-02-01, Definition of an Accident, records the following in part:
Accident includes
a willful and intentional act, not being the act of the worker
a chance event occasioned by a physical or natural cause, and
a disablement arising out of and in the course of employment.
Chance event
A chance event is defined as an identifiable unintended event which causes an injury. An injury itself is not a chance event.
Disablement
The definition of disablement includes
a condition that emerges gradually over time
an unexpected result of working duties.
In addition to the above applicable Policies, I also considered entitlement under the claim based upon whether the worker’s accident history significantly contributed to their diagnosis.
While there is much information on strokes in general and on vertebral artery dissection in literature and on the internet, I note that in a recent WSIAT decision, the WSIAT Panel requested a medical opinion on the specific topic of vertebral artery dissection leading to a stroke. Although the WSIAT decision in question, 1324/21, described somewhat different circumstances compared to this particular case, the opinion of Dr. Kertesz, which was obtained by the WSIAT Panel, nonetheless provides relevant information on the topic of vertebral artery dissection which can be applied to this case.
Dr. Kertesz’s opinion in WSIAT decision 1824/21 was cited to assist the WSIAT Panel in arriving at a decision. Dr. Kertesz, is a Neurologist and Professor Emeritus, Department of Clinical Neurological Services, University of Western Ontario. The salient portions of Dr. Kertesz’s opinion which are relevant to this decision are as follows:
Dissection is the result of a process of the weakening and coming apart of the layers of the arterial wall connective tissue that goes on well before symptoms or its trigger occur. Eventually
it reaches a stage when the deformity causes arterial obstruction or clotting. An analogy is the
structural weakening of a building or a bridge that takes place over time and may show some signs of damage before it actually collapses. In this case the migraine* could be analogous to the
appearance of cracks before the collapse, which here would be the analogy for the obstruction and clotting that caused the stroke.
(* the worker in this particular claim also described a 10/10 headache at the onset of their symptoms)
Dissection does not always lead to a stroke…Dissection is often discovered when an angiogram is done for some other reason such as pain or transient neurological symptoms.
Dissection most often leads to a stroke without a precipitating event, but exertion, twisting of the neck, direct trauma, etc. are often (40 % of the case reports) described as triggers. These are common occurrences which everyone experiences and they are not the cause but only the triggers of symptomatic occlusion, clotting or pain in the artery. Again, the analogy of trains passing safely over the cracked bridge several times a day until one day one train causes the actual break and collapse, is useful here. It is unlikely that ordinary exertion would tear a normal artery apart.
Migraines are of course common without dissections but their occurrence in the period before the stroke suggests the vascular reaction related to the dissections. As described above, dissection is a structural defect in the artery that likely takes months to develop and at times has a
genetic cause as evidenced by familial occurrence. The cause is unknown in the majority
of the cases and triggers are present only in less than half of the cases.
The distinction between minor or severe neck trauma is not easy in individual cases. Severe direct injuries to the neck or extreme manipulation may cause dissection in healthy arteries which is not the same as the spontaneous dissection of the arteries … This “idiopathic” (cause unknown), possibly genetically determined dissection is the most common cause of spontaneous
carotid dissections in which a family history of dissection significantly increases one’s risk and it most often comes to light without trauma. The role of trauma and exertion is often debated in the literature as in the following quote:
“Cervicocerebral dissections are often preceded by some form of trauma to the neck. However, the severity of trauma can range from a trivial injury to severe roadside accidents involving direct
injury to the neck arteries. Practically, all forms of neck trauma have been reported to be associated with dissection, including chiropractic manoeuvres, vigorous coughing or nose blowing, sudden neck turning as in reversing a car, prolonged telephone conversations, road accidents, inflicting direct trauma to a cervical artery, strangulations, bar fights, recent surgery involving prolonged anaesthesia, etc. It is conceivable that trauma leads to a tear in the intima or media. However, it is difficult to explain how minor neck trauma can cause dissection of the arteries and in many cases there is no clear history of antecedent trauma.” (6).
The general medical literature confirms that risk factors for stroke include, but are not limited to: high blood pressure; family history of stroke; diabetes; heart disease; high cholesterol and lipid levels; oral contraceptives; history of transient ischemic attacks (TIAs); smoking; and excessive alcohol consumption.
The file medical information confirms the worker had several risk factors for stroke. I note Dr. Basir’s February 18, 2022 report confirms the worker’s family history was significant for stroke as their father who died at age 68 due to stroke. The medical information also confirms the worker had uncontrolled diabetes at the time of admission to hospital, and that the worker’s medical history included hypertension, according to Dr. Guzman’s February 21, 2022 report. Furthermore, Dr. Guzman also noted the worker had smoked just less than half a pack per day for approximately 30 years.
Despite the worker’s above risk factors for stroke, entitlement may still nonetheless be accepted under the claim if the worker’s occupational activities are determined to be a significant contributing factor to the vertebral artery dissection which led to their stroke. This is based upon the “thin skull principle”, a common-law doctrine which states that one must take victims of an accident as they are, despite any pre-existing conditions.
In this particular case, the worker confirmed in testimony that they performed work at X Hospital on February 11, 2022, from 12:00 pm until 8:00 pm on the day in question. Although the file information documents the worker performed work from 8:00 am until 4:00 pm on this day, I nevertheless accept the worker performed a full day of work despite the minor discrepancy in relation to the time worked. Given the worker’s description of the tight space in which they worked, I also find it would be reasonable and logical to accept the worker’s testimony that they likely ‘bumped’ their head and/or neck, and other body parts on that day multiple times in an effort to perform their job duties on February 11, 2022.
However, in light of the narrow space in which the worker described that they performed their work on February 11, 2022, I find that any ‘bumping’ of the head, neck or body that occurred was likely extremely minor or negligible. An important factor to consider is that the worker did not report a head and/or neck injury to any person present during the radiator repair on February 11, 2022, nor did the employer have knowledge or reports of the worker having injured themself on this day. Furthermore, none of the contemporaneous medical reports support the worker sustained injury to their head and/or neck on February 11, 2022. In fact, Dr. Visser noted in the February 16, 2022 hospital report that the worker denied any associated neck pain or neck stiffness and that examination revealed full range of motion of their neck. There was no head or neck injury report to the hospital in any of their initial visits.
It was only 1.5 months following the worker’s initial visit to hospital on February 13, 2022 that Dr. Migay documented in their March 25, 2022 report that the worker reported they hit their head twice, once under the furnace and then again inside the furnace unit.
I note that Dr. Sweet recorded a somewhat different accident history in their February 18, 2022 report compared to what has been claimed and/or documented. Dr. Sweet suggested that the worker had sustained a neck twisting injury and/or lifting injury which caused their vertebral artery dissection leading to a stroke. I do not find this accident history is consistent with the accident history reported or the file information – this is the only instance where a neck twist and/or lifting injury is mentioned. Furthermore, this accident history is also inconsistent with Dr. Visser’s contemporaneous examination of the worker on February 16, 2022 at the hospital emergency when the worker denied any associated neck pain or neck stiffness and the worker was found to have full range of motion of their neck. It is also inconsistent with all of the other medical reports submitted to file with respect to the worker’s accident history. As a result, I will lend minimal weight to the accident history documented in this report.
Based on the above information, I therefore accept that although the worker likely ‘bumped’ their head and/or neck on multiple occasions during the course of their workday on February 11, 2022, the ‘bumping’ of their head and/or neck was likely negligible.
Apart from Dr. Sweet’s report above, I note that there has not been any other medical practitioner or specialist who treated the worker who opined that the worker’s vertebral artery dissection leading to a stroke was a consequence of their employment duties, or that it had played a significant factor leading to their stroke.
An important consideration when determining entitlement in the claim is the onset of the worker’s symptoms. According to the file medical information and the worker’s testimony, the worker’s symptoms began on February 13, 2022, two days after having performed the radiator repair work at X Hospital on February 11, 2022. I note the worker also testified, and the file information confirms, that they attended an additional two calls the following day, i.e. February 12, 2022, without incident, and with no reports of the symptoms experienced on February 13, 2022.
In summary, given the elapsed time from February 11, 2022 until the worker’s onset of symptoms on February 13, 2022, and when considering the worker’s significant pre-existing risk factors for stroke, I am unable to conclude that the specific duties they performed on February 11, 2022 were a significant contributing factor to the development of their vertebral artery dissection which led to their stroke. As is noted in Dr. Kertesz’s citation above, it is difficult to explain how minor neck trauma can cause dissection of the arteries and in many cases, there is no clear history of antecedent trauma.
Having regard for all of the above, I therefore find it has not been demonstrated that the worker’s occupational duties on February 11, 2022 were a significant contributing factor to the development of their vertebral artery dissection which ultimately led to a stroke. As a result, in accordance with Policy 15-02-01, I therefore conclude the worker did not sustain a ‘disablement arising out of and in the course of employment’.
Policy 11-01-01, Adjudicative Process, specifies that an allowable claim must meet all five points, as is documented above. In light of my conclusion that the worker did not sustain a ‘disablement arising out of and in the course of employment’, I therefore also find that the third and fifth points, i.e. ‘personal work-related injury’, and ‘compatibility of diagnosis to accident or disablement history’ have not been established. As the worker has not met all five points for an allowable claim, I therefore conclude the worker does not have initial entitlement to a vertebral artery dissection which led to a stroke.
CONCLUSION
I conclude the worker does not have initial entitlement to a vertebral artery dissection leading to a stroke under the claim.
The worker’s objection is therefore denied.
DATED January 18, 2023
L. Diaz
Appeals Resolution Officer
Appeals Services Division