Allison E Arch1, David C Weisman1, Steven Coca1, Karin V Nystrom1, Charles R Wira1, Joseph L Schindler2. 1. From the Departments of Neurology (A.E.A., K.V.N., J.L.S.), Medicine (S.C.), and Emergency Medicine (C.R.W.), Yale University School of Medicine, New Haven, CT; and Department of Neurology, Abington Hospital-Jefferson Health, Abington, PA (D.C.W.). 2. From the Departments of Neurology (A.E.A., K.V.N., J.L.S.), Medicine (S.C.), and Emergency Medicine (C.R.W.), Yale University School of Medicine, New Haven, CT; and Department of Neurology, Abington Hospital-Jefferson Health, Abington, PA (D.C.W.). joseph.schindler@yale.edu.
Abstract
BACKGROUND AND PURPOSE: The failure to recognize an ischemic stroke in the emergency department is a missed opportunity for acute interventions and for prompt treatment with secondary prevention therapy. Our study examined the diagnosis of acute ischemic stroke in the emergency department of an academic teaching hospital and a large community hospital. METHODS: A retrospective chart review was performed from February 2013 to February 2014. RESULTS: A total of 465 patients with ischemic stroke were included in the analysis; 280 patients from the academic hospital and 185 patients from the community hospital. One hundred three strokes were initially misdiagnosed that is 22% of the included strokes at the combined centers. Fifty-five of these were missed at the academic hospital (22%) [corrected] and 48 were at the community hospital (26%, P=0.11). Thirty-three percent of missed cases presented within a 3-hour time window for recombinant tissue-type plasminogen activator eligibility. An additional 11% presented between 3 and 6 hours of symptom onset for endovascular consideration. Symptoms independently associated with greater odds of a missed stroke diagnosis were nausea/vomiting (odds ratio, 4.02; 95% confidence interval, 1.60-10.1), dizziness (odds ratio, 1.99; 95% confidence interval, 1.03-3.84), and a positive stroke history (odds ratio, 2.40; 95% confidence interval, 1.30-4.42). Thirty-seven percent of posterior strokes were initially misdiagnosed compared with 16% of anterior strokes (P<0.001). CONCLUSIONS: Atypical symptoms associated with posterior circulation strokes lead to misdiagnoses. This was true at both an academic center and a large community hospital. Future studies need to focus on the evaluation of identification systems and tools in the emergency department to improve the accuracy of stroke diagnosis.
BACKGROUND AND PURPOSE: The failure to recognize an ischemic stroke in the emergency department is a missed opportunity for acute interventions and for prompt treatment with secondary prevention therapy. Our study examined the diagnosis of acute ischemic stroke in the emergency department of an academic teaching hospital and a large community hospital. METHODS: A retrospective chart review was performed from February 2013 to February 2014. RESULTS: A total of 465 patients with ischemic stroke were included in the analysis; 280 patients from the academic hospital and 185 patients from the community hospital. One hundred three strokes were initially misdiagnosed that is 22% of the included strokes at the combined centers. Fifty-five of these were missed at the academic hospital (22%) [corrected] and 48 were at the community hospital (26%, P=0.11). Thirty-three percent of missed cases presented within a 3-hour time window for recombinant tissue-type plasminogen activator eligibility. An additional 11% presented between 3 and 6 hours of symptom onset for endovascular consideration. Symptoms independently associated with greater odds of a missed stroke diagnosis were nausea/vomiting (odds ratio, 4.02; 95% confidence interval, 1.60-10.1), dizziness (odds ratio, 1.99; 95% confidence interval, 1.03-3.84), and a positive stroke history (odds ratio, 2.40; 95% confidence interval, 1.30-4.42). Thirty-seven percent of posterior strokes were initially misdiagnosed compared with 16% of anterior strokes (P<0.001). CONCLUSIONS: Atypical symptoms associated with posterior circulation strokes lead to misdiagnoses. This was true at both an academic center and a large community hospital. Future studies need to focus on the evaluation of identification systems and tools in the emergency department to improve the accuracy of stroke diagnosis.
Authors: Benjamin Nham; Nicole Reid; Kendall Bein; Andrew P Bradshaw; Leigh A McGarvie; Emma C Argaet; Allison S Young; Shaun R Watson; G Michael Halmagyi; Deborah A Black; Miriam S Welgampola Journal: J Neurol Date: 2021-08-16 Impact factor: 4.849
Authors: Grant C O'Connell; Megan L Alder; Christine G Smothers; Julia H C Chang Journal: Proc Natl Acad Sci U S A Date: 2020-08-06 Impact factor: 11.205
Authors: Alexander Andrea Tarnutzer; Seung-Han Lee; Karen A Robinson; Zheyu Wang; Jonathan A Edlow; David E Newman-Toker Journal: Neurology Date: 2017-03-29 Impact factor: 9.910
Authors: Marja-Liisa Sumelahti; Merika S Sumanen; Kari J Mattila; Lauri Sillanmäki; Markku Sumanen Journal: BMC Public Health Date: 2021-06-07 Impact factor: 3.295