Diagnosis of stroke by the nonneurologist. A validation study

Frequency and Characteristics of Non-Neurological and Neurological Stroke Mimics in the Emergency Department

BACKGROUND

Stroke mimics are common in the emergency department (ED) and early detection is important to initiate appropriate treatment and withhold unnecessary procedures. We aimed to compare the frequency, clinical characteristics and predictors of non-neurological and neurological stroke mimics transferred to our ED for suspected stroke.

METHODS

This was a cross-sectional study of consecutive patients with suspected stroke transported to the ED of the University Hospital Essen between January 2017 and December 2021 by the city's Emergency Medical Service. We investigated patient characteristics, preclinical data, symptoms and final diagnoses in patients with non-neurological and neurological stroke mimics. Multinominal logistic regression analysis was performed to assess predictors of both etiologic groups.

RESULTS

Of 2167 patients with suspected stroke, 762 (35.2%) were diagnosed with a stroke mimic. Etiology was non-neurological in 369 (48.4%) and neurological in 393 (51.6%) cases. The most common diagnoses were seizures (23.2%) and infections (14.7%). Patients with non-neurological mimics were older (78.0 vs. 72.0 y, p < 0.001) and more likely to have chronic kidney disease (17.3% vs. 9.2%, p < 0.001) or heart failure (12.5% vs. 7.1%, p = 0.014). Prevalence of malignancy (8.7% vs. 13.7%, p = 0.031) and focal symptoms (38.8 vs. 57.3%, p < 0.001) was lower in this group. More than two-fifths required hospitalization (39.3 vs. 47.1%, p = 0.034). Adjusted multinominal logistic regression revealed chronic kidney and liver disease as independent positive predictors of stroke mimics regardless of etiology, while atrial fibrillation and hypertension were negative predictors in both groups. Prehospital vital signs were independently associated with non-neurological stroke mimics only, while age was exclusively associated with neurological mimics.

CONCLUSIONS

Up to half of stroke mimics in the neurological ED are of non-neurological origin. Preclinical identification is challenging and a high proportion requires hospitalization. Awareness of underlying etiologies and differences in clinical characteristics is important to provide optimal care.

A systematic review and meta-analysis to evaluate the diagnostic accuracy of recognition of stroke in the emergency department (ROSIER) scale

BACKGROUND

The present study aims to evaluate the performance and the clinical applicability of the Recognition of Stroke in the Emergency Department (ROSIER) scale via systematic review and meta-analysis.

METHODS

Electronic databases of Pubmed and Embase were searched between 1st January 2005 (when ROSIER developed) and 8th May 2020. Studies that evaluated the diagnostic accuracy of the ROSIER scale were included. The sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curve (AUC) were combined using a bivariate mixed-effects model. Fagan nomogram was used to evaluate the clinical applicability of the ROSIER scale.

RESULTS

A total of 14 studies incorporating 15 datasets were included in this meta-analysis. The combined sensitivity, specificity, DOR and AUC were 0.88 [95% confidence interval (CI): 0.83-0.91], 0.66 (95% CI: 0.52-0.77), 13.86 (95% CI, 7.67-25.07) and 0.88 (95% CI, 0.85-0.90), respectively. Given the pre-test probability of 60.0%, Fagan nomogram suggested the post-test probability was increased to 79% when the ROSIER was positive. In comparison, it was decreased to 22% when ROSIER was negative. Subgroup analysis showed that the pooled sensitivity of ROSIER in the European population was higher than that in Asia. In contrast, the pooled specificity was not significantly different between them. Moreover, results also suggested the male-to-female ratio ≤ 1.0 subgroup, prehospital setting subgroup, and other trained medical personnel subgroup had significantly higher sensitivity compared with their counterparts. At the same time, no significant differences were found in the pooled specificity between them.

CONCLUSIONS

ROSIER is a valid scale with high clinical applicability, which has not only good diagnostic accuracy in Europe but also shows excellent performance in Asia. Moreover, the ROSIER scale exhibits good applicability in prehospital settings with other trained medical personnel.

Migraine History: A Predictor of Negative Diffusion-Weighted Imaging in IV-tPA-Treated Stroke Mimics

BACKGROUND

Migraine, seizures, and psychiatric disorders are frequently reported as "stroke mimics" in patients with negative diffusion-weighted imaging (DWI) after IV-tPA. We sought to determine predictors of negative DWI in suspected stroke patients treated with IV-tPA.

METHOD

A retrospective case-control study encompassing all acute stroke patients treated with IV-tPA (at our hospital or "dripped and shipped") from January 2013 to December 2014 was con- ducted. A total of 275 patients were identified with 47 negative DWI cases and 228 positive DWI controls. Variables including demographic factors, stroke characteristics, and clinical comorbidities were analyzed for statistical significance. A multivariate logistic regression was performed (SPSS-24) to identify predictors of negative DWI.

RESULTS

Approximately 17% of patients had negative DWI after IV-tPA. Compared to controls, migraine history independently predicted negative DWI (odds ratio [OR] 5.0 95% confidence interval [CI] 1.03-24.6, P = .046). Increasing age (OR .97 95% CI .94-.99, P = .02) and atrial fibrillation (OR .25 95% CI .08-.77, P = .01) predicted lower probability of negative DWI. Gender, admission NIHSS, treatment location, preadmission modified Rankin scale, diabetes mellitus, hypertension, hyperlipidemia, symptom side, seizure history, and psychiatric history did not predict negative DWI status.

CONCLUSIONS

In our study, roughly 1 in 6 patients treated with IV-tPA were later found to be stroke mimics with negative DWI. Despite a high proportion of suspected stroke mimics in our study, only preexisting migraine history independently predicted negative DWI status after IV-tPA treatment in suspected stroke patients.

Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack

BACKGROUND

Rapid and accurate detection of stroke by paramedics or other emergency clinicians at the time of first contact is crucial for timely initiation of appropriate treatment. Several stroke recognition scales have been developed to support the initial triage. However, their accuracy remains uncertain and there is no agreement which of the scales perform better.

OBJECTIVES

To systematically identify and review the evidence pertaining to the test accuracy of validated stroke recognition scales, as used in a prehospital or emergency room (ER) setting to screen people suspected of having stroke.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and the Science Citation Index to 30 January 2018. We handsearched the reference lists of all included studies and other relevant publications and contacted experts in the field to identify additional studies or unpublished data.

SELECTION CRITERIA

We included studies evaluating the accuracy of stroke recognition scales used in a prehospital or ER setting to identify stroke and transient Ischemic attack (TIA) in people suspected of stroke. The scales had to be applied to actual people and the results compared to a final diagnosis of stroke or TIA. We excluded studies that applied scales to patient records; enrolled only screen-positive participants and without complete 2 × 2 data.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted a two-stage screening of all publications identified by the searches, extracted data and assessed the methodologic quality of the included studies using a tailored version of QUADAS-2. A third review author acted as an arbiter. We recalculated study-level sensitivity and specificity with 95% confidence intervals (CI), and presented them in forest plots and in the receiver operating characteristics (ROC) space. When a sufficient number of studies reported the accuracy of the test in the same setting (prehospital or ER) and the level of heterogeneity was relatively low, we pooled the results using the bivariate random-effects model. We plotted the results in the summary ROC (SROC) space presenting an estimate point (mean sensitivity and specificity) with 95% CI and prediction regions. Because of the small number of studies, we did not conduct meta-regression to investigate between-study heterogeneity and the relative accuracy of the scales. Instead, we summarized the results in tables and diagrams, and presented our findings narratively.

MAIN RESULTS

We selected 23 studies for inclusion (22 journal articles and one conference abstract). We evaluated the following scales: Cincinnati Prehospital Stroke Scale (CPSS; 11 studies), Recognition of Stroke in the Emergency Room (ROSIER; eight studies), Face Arm Speech Time (FAST; five studies), Los Angeles Prehospital Stroke Scale (LAPSS; five studies), Melbourne Ambulance Stroke Scale (MASS; three studies), Ontario Prehospital Stroke Screening Tool (OPSST; one study), Medic Prehospital Assessment for Code Stroke (MedPACS; one study) and PreHospital Ambulance Stroke Test (PreHAST; one study). Nine studies compared the accuracy of two or more scales. We considered 12 studies at high risk of bias and one with applicability concerns in the patient selection domain; 14 at unclear risk of bias and one with applicability concerns in the reference standard domain; and the risk of bias in the flow and timing domain was high in one study and unclear in another 16.We pooled the results from five studies evaluating ROSIER in the ER and five studies evaluating LAPSS in a prehospital setting. The studies included in the meta-analysis of ROSIER were of relatively good methodologic quality and produced a summary sensitivity of 0.88 (95% CI 0.84 to 0.91), with the prediction interval ranging from approximately 0.75 to 0.95. This means that the test will miss on average 12% of people with stroke/TIA which, depending on the circumstances, could range from 5% to 25%. We could not obtain a reliable summary estimate of specificity due to extreme heterogeneity in study-level results. The summary sensitivity of LAPSS was 0.83 (95% CI 0.75 to 0.89) and summary specificity 0.93 (95% CI 0.88 to 0.96). However, we were uncertain in the validity of these results as four of the studies were at high and one at uncertain risk of bias. We did not report summary estimates for the rest of the scales, as the number of studies per test per setting was small, the risk of bias was high or uncertain, the results were highly heterogenous, or a combination of these.Studies comparing two or more scales in the same participants reported that ROSIER and FAST had similar accuracy when used in the ER. In the field, CPSS was more sensitive than MedPACS and LAPSS, but had similar sensitivity to that of MASS; and MASS was more sensitive than LAPSS. In contrast, MASS, ROSIER and MedPACS were more specific than CPSS; and the difference in the specificities of MASS and LAPSS was not statistically significant.

AUTHORS' CONCLUSIONS

In the field, CPSS had consistently the highest sensitivity and, therefore, should be preferred to other scales. Further evidence is needed to determine its absolute accuracy and whether alternatives scales, such as MASS and ROSIER, which might have comparable sensitivity but higher specificity, should be used instead, to achieve better overall accuracy. In the ER, ROSIER should be the test of choice, as it was evaluated in more studies than FAST and showed consistently high sensitivity. In a cohort of 100 people of whom 62 have stroke/TIA, the test will miss on average seven people with stroke/TIA (ranging from three to 16). We were unable to obtain an estimate of its summary specificity. Because of the small number of studies per test per setting, high risk of bias, substantial differences in study characteristics and large between-study heterogeneity, these findings should be treated as provisional hypotheses that need further verification in better-designed studies.

Improper Use of Thrombolytic Agents in Acute Hemiparesis Following Misdiagnosis of Acute Ischemic Stroke

Objective

Acute hemiparesis is often an early presentation of acute ischemic stroke, though it can occur in various disorders. This study aimed to investigate the improper use of thrombolytic agents for patients with acute hemiparesis, following the misdiagnosis of acute ischemic stroke.

Methods

We analyzed the clinical and radiological data of nine patients initially misdiagnosed with cerebral stroke in the emergency room from May 2013 to January 2017. All the patients were treated with tissue plasminogen activator (TPA) owing to the presence of acute hemiparesis. Subsequently, emergent computed tomography scan showed no intracranial hemorrhage. Clinical findings including neurological deficits, clinical course, and related complications were detected and analyzed.

Results

Acute hemiparesis was observed in the following conditions: spontaneous spinal epidural hematoma, Brown-Séquard syndrome caused by cervical disc herniation, cervical epidural abscess, hypoglycemia in the presence of an old stroke, and seizure or convulsion disorder. Although acute hemiparesis was regarded as a contraindication, inappropriate TPA administration did not aggravate the neurological condition in any of the patients who required surgery.

Conclusion

Upon presentation of acute hemiparesis, various conditions mimicking cerebral stroke should be considered to avoid misdiagnosis. We suggest that physicians should exercise caution when prescribing thrombolytic agents.

Door to needle time and functional outcome for mild ischemic stroke over telestroke

INTRODUCTION

Faster intravenous alteplase (tPA) administration from time of symptom onset is associated with better functional outcome. Lack of recognition of mild ischemic stroke (MIS) might result in delay in treatment with tPA. We hypothesise that patients with MIS have a longer door to needle (DTN) time when compared to patients with severe stroke symptoms.

METHODS

Data on all patients who received tPA at spoke hospitals through the Medical University of South Carolina (MUSC) telestroke network were analysed. Collected data included baseline characteristics, stroke severity on presentation measured by the National Institute of Health Stroke Scale (NIHSS), the rate of symptomatic intracerebral haemorrhage, discharge location, and discharge functional outcome measured by the modified Rankin scale.

RESULTS AND DISCUSSION

Of the 454 patients treated with tPA through the MUSC telestroke network in the period from January 2013 to April 2017, 98 (22%) had MIS defined as NIHSS ≤ 5 on presentation; the remaining 356 (78%) patients were found to have severe stroke defined as NIHSS > 5 on presentation. Patients presenting with MIS were found to have a delay in receiving intravenous tPA by ∼10 min (p = 0.007) and approximately 15% of them had poor functional outcome at discharge. Patients with a MIS on presentation have significantly more prolonged DTN time. Nearly 15% of low severity strokes had poor outcome even after receiving tPA.

When migraine mimics stroke: A systematic review

BACKGROUND

Migraine with aura may mimic an acute ischemic stroke, so that an improper administration of thrombolytic treatment can expose migrainous patients to severe adverse effects.

METHODS

This systematic review quantifies the relevance of migraine with aura among stroke mimics, checking for thrombolysis' safety in these patients. We reviewed the literature after 1995, distinguishing from studies dealing with stroke mimics treated with systemic thrombolysis and those who were not treated with systemic thrombolysis.

RESULTS

Migraine with aura is responsible for 1.79% (CI 95% 0.82-3.79%) of all the emergency Stroke Unit evaluations and it represents 12.24% (CI 95% 6.34-22.31%) of stroke mimics in the group not treated with systemic thrombolysis. 6.65% (CI 95% 4.32-9.78%) of systemic thrombolysis administrations are performed in patients without an acute ischemic stroke. Migraine with aura is responsible for 17.91% of these (CI 95% 13.29-23.71%). The reported rate of adverse events seems extremely low (0.01%).

CONCLUSION

Migraine with aura is the third most common stroke mimic, following seizures and psychiatric disorders; it is responsible for about 18% of all improper thrombolytic treatments. Despite the absence of strong supporting data, thrombolysis in migraine with aura seems to be a procedure with an extremely low risk of adverse events.

Increase in the Admission of Stroke Mimics after Change in Emergency Shifts

BACKGROUND

In 2010, changes were made to the shift pattern of neurology residents for cover in the Emergency Department at a university hospital. This resulted in a decrease in the number of emergency hours worked by neurology specialists and allowed for a natural quasi-experiment.

AIM

We aimed to evaluate if changes to the number of emergency hours worked by neurology residents and specialist neurologists, (intervention) altered the number or pattern of admitted stroke mimics (SMs).

METHODS

Observational retrospective study from January 2007 to December 2013. Time of intervention was set as August 2010. We used a segmented linear regression - ARIMA - to evaluate changes in the temporal pattern of admitted SMs. A statistical correlation between the number of emergency hours worked by neurology residents and the number of admitted SMs was calculated using the Pearson Correlation Coefficient.

RESULTS

Of the 2,552 patients admitted to the stroke unit, 290 were SMs (11.4%). After August 2010, there was an increase in the number of admitted SMs (p = 0.003). After 2010, the most frequent SM diagnosis changed from a psychiatric condition to peripheral vertigo. A positive correlation was found between the number of hours worked primarily by neurology residents and the number of admitted SMs (Pearson correlation coefficient = 0.94; p = 0.002).

CONCLUSIONS

Changes in the pattern of Emergency Department shifts were associated with an increase in the rate of admitted SMs and with a higher number of mimics with a final diagnosis of peripheral vertigo.

Acute Stroke and Transient Ischemic Attack in the Outpatient Clinic

Ischemic stroke is cause of substantial death and disability in the United States. Transient ischemic attack, a precursor to ischemic stroke, conveys a high risk of recurrent stroke within 90 days from event. These conditions are highly preventable and treatable. The cause is heterogenous and includes atherothrombosis, cardioembolism, lacunar disease, or cryptogenic, and some uncommon causes, such as arterial dissection and prothrombotic states. The emergent evaluation includes establishing time of onset, vital signs, glucose level, and severity of the deficit.

ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis

OBJECTIVE

With the emergency department (ED) being a high-risk site for diagnostic errors, we sought to estimate ED diagnostic accuracy for identifying acute cerebrovascular events.

METHODS

MEDLINE and Embase were searched for studies (1995-2016) reporting ED diagnostic accuracy for ischemic stroke, TIA, or subarachnoid hemorrhage (SAH). Two independent reviewers determined inclusion. We identified 1,693 unique citations, examined 214 full articles, and analyzed 23 studies. Studies were rated on risk of bias (QUADAS-2). Diagnostic data were extracted. We prospectively defined clinical presentation subgroups to compare odds of misdiagnosis.

RESULTS

Included studies reported on 15,721 patients. Studies were at low risk of bias. Overall sensitivity (91.3% [95% confidence interval (CI) 90.7-92.0]) and specificity (92.7% [91.7-93.7]) for a cerebrovascular etiology was high, but there was significant variation based on clinical presentation. Misdiagnosis was more frequent among subgroups with milder (SAH with normal vs abnormal mental state; false-negative rate 23.8% vs 4.2%, odds ratio [OR] 7.03 [4.80-10.31]), nonspecific (dizziness vs motor findings; false-negative rate 39.4% vs 4.4%, OR 14.22 [9.76-20.74]), or transient (TIA vs ischemic stroke; false discovery rate 59.7% vs 11.7%, OR 11.21 [6.66-18.89]) symptoms.

CONCLUSIONS

Roughly 9% of cerebrovascular events are missed at initial ED presentation. Risk of misdiagnosis is much greater when presenting neurologic complaints are mild, nonspecific, or transient (range 24%-60%). This difference suggests that many misdiagnoses relate to symptom-specific factors. Future research should emphasize studying causes and designing error-reduction strategies in symptom-specific subgroups at greatest risk of misdiagnosis.

Development of a new stroke scale in an emergency setting

Background

Early identification of stroke is crucial to maximize early management benefits in emergency departments. This study aimed to develop and validate a new stroke recognition instrument for differentiating acute stroke from stroke mimics in an emergency setting.

Methods

A prospective observational cohort study among suspected stroke patients presenting to Emergency Department in the Second Affiliated Hospital of Guangzhou Medical University was conducted from May 2012 to March 2013. The symptoms and signs of suspected stroke patients were collected. Logistic regression analysis was used to identify the factors associated with acute stroke. The symptoms and signs closely associated with acute stroke were selected to develop the new stroke scale, Guangzhou Stroke Scale (GZSS). The diagnostic value of GZSS was then compared with ROSIER, FAST and LAPSS. The primary outcome was confirmed stroke by CT within 24 h.

Results

Four hundred and sixteen suspected stroke patients (247 ischemia, 107 hemorrhage, 4 transient ischemic attack, 58 non-stroke) were assessed. A new stroke scale, GZSS (total score from −1 to 8.5), was developed and consisted of nine parameters: vertigo (−1), GCS ≤ 8 (+2), facial paralysis (+1), asymmetric arm weakness (+1), asymmetric leg weakness (+1), speech disturbance (+0.5), visual field defect (+1), systolic blood pressure ≥145 mmHg (+1) and diastolic blood pressure ≥95 mmHg (+1). Among the four scales, the discriminatory value (C-statistic) of GZSS was the best (AUC: 0.871 (p < 0.001) when compared to ROSIER (0.772), LAPSS (0.722) and FAST (0.699). At an optimal cut-off score of >1.5 on a scale from −1 to 8.5, the sensitivity and specificity of GZSS were 83.2 and 74.1 %, whilst the sensitivities and specificities of ROSIER were 77.7 and 70.7 %, FAST were 76.0 and 63.8 %, LAPSS were 56.4 and 87.9 %.

Conclusion

GZSS had better sensitivity than existing stroke scales in Chinese patients with suspected stroke. Further studies should be conducted to confirm its effectiveness in the initial differentiation of acute stroke from stroke mimics.

Inter-Observer Agreement on Diffusion-Weighted Magnetic Resonance Imaging Interpretation for Diagnosis of Acute Ischemic Stroke Among Emergency Physicians

Objectives

Diffusion-weighted magnetic resonance imaging (DW-MRI) is a highly sensitive tool for the detection of early ischemic stroke and is excellent at detecting small and early infarcts. Nevertheless, conflict may arise and judgments may differ among different interpreters. Inter-observer variability shows the systematic difference among different observers and is expressed as the kappa (Κ) coefficient. In this study, we aimed to determinate the inter-observer variability among emergency physicians in the use of DW-MRI for the diagnosis of acute ischemic stroke.

Methods

Cranial DW-MRI images of 50 patients were interpreted in this retrospective observational cross-sectional study. Patients who were submitted to DW-MRI imaging for a suspected acute ischemic stroke were included in the study, unless the scans were ordered by any of the reviewers or they were absent in the system. The scans were blindly and randomly interpreted by four emergency physicians. Inter-observer agreement between reviewers was evaluated using Fleiss’ Κ statistics.

Results

The mean kappa value for high signal on diffusion-weighted images (DWI) and for reduction on apparent diffusion coefficient (ADC) were substantial (k=0.67) and moderate (k=0.60) respectively. The correlation for detection of the presence of ischemia and location was substantial (k: 0.67). There were 18 false-positive and 4 false-negative evaluations of DWI, 15 false positive and 8 false-negative evaluations of ADC.

Conclusions

Our data suggest that DW-MRI is reliable in screening for ischemic stroke when interpreted by emergency physicians in the emergency department. The levels of stroke identification and variability show that emergency physicians may have an acceptable level of agreement.

Common Neurological Disorders Involving Inpatient Liaisons at a Secondary Referral Hospital in Taiwan: A Retrospective Cross-Sectional Study

Background and Purpose

The requirement for neurology liaison is increasing in accordance with the growing health care demands associated with aging populations. The aim of this study was to characterize the nature of neurological inpatient liaisons (NILs) to help plan for the appropriate use of neurology resources.

Methods

This was a retrospective cross-sectional study of NILs in a secondary referral hospital over a 12-month period.

Results

There were 853 neurological consultations with a liaison rate of 3% per admission case. Chest medicine, gastroenterology, and infectious disease were the three most frequent specialties requesting liaison, and altered consciousness, seizure, and stroke were the three most frequent disorders for which a NIL was requested. Infection was the most common cause of altered consciousness. Epilepsy, infection, and previous stroke were common causes of seizure disorders. Acute stroke accounted for 44% of all stroke disorders. Electroencephalography was the most recommended study, and was also the most frequently performed. Ninety-five percent of emergency consultations were completed within 2 hours, and 85% of regular consultations were completed within 24 hours. The consult-to-visit times for emergency and regular consultations were 44±47 minutes (mean±standard deviation) and 730±768 minutes, respectively, and were shorter for regular consultations at intensive care units (p=0.0151) and for seizure and stroke disorders (p=0.0032).

Conclusions

Altered consciousness, seizure, and stroke were the most common reasons for NILs. Half of the patients had acute neurological diseases warranting immediate diagnosis and treatment by the consulting neurologists. Balancing increasing neurologist workloads and appropriate health-care resources remains a challenge.

A prospective evaluation of indications for neurological consultation in the emergency department

Background

Recognizing the diverse presentation of neurological conditions that emergency physicians encounter can be challenging, and management of these patients often requires consultation with a neurologist. Accurate diagnosis is critical in neurological emergencies because patient outcomes are often dependent on timely treatment. Our primary objective was to ascertain whether consultant neurologists understood the reason for consultation in the emergency department.

Methods

The authors conducted a prospective study of a non-consecutive sample of 94 patients seen in an academic tertiary care emergency department (ED) who underwent consultation by neurologist over 4 consecutive months. At the time a consult was requested, we independently surveyed the treating ED physician for their differential diagnosis. Neurologists were also queried as to whether there was a clear indication for consultation. We then followed the patients to determine their final diagnosis and outcome.

Results

The median age was 57 years (interquartile range 45–78). 45.7 % were male. The clinical reasons for all the consults were 61 % focal symptom, 12 % concern about a specific diagnosis, 9 % radiological finding, 9 % diagnostic ambiguity, and 11 % other. There was no significant difference in the rate of a final neurological diagnosis based on the clinical reason for consult (p = 0.13). In the 17 % of patients for whom the treating neurologist reported a lack of a clear indication for the consultation, 25 % were later admitted to a neurological service, and 69 % ultimately had a neurological diagnosis.

Conclusions

Although patients with neurological emergencies can have diverse presentations, emergency physicians appear to utilize neurologic consultation appropriately. Additionally, nearly 70 % of patients for whom the consultant did not precisely understand the need for the consultation had neurological diagnoses. Time and resource constraints in the ED create challenges in making correct diagnosis.

Misdiagnosis of stroke

Rapid diagnosis of stroke is necessary for the timely delivery of thrombolysis and evaluation of novel therapies such as neuroprotection. An accurate clinical history and competent examination are key to identifying which patients are likely to have had a stroke and arranging and interpreting neuroimaging. Stroke symptoms are typically acute in onset, but are highly variable depending on the vascular territory affected. Common presenting symptoms are limb weakness, and speech and visual disturbances. Common stroke mimics are seizures, space occupying lesions, syncope, somatization and delirium secondary to sepsis. Stroke recognition instruments can help nonspecialists in the early diagnosis of stroke, with studies reporting sensitivity of over 90% and specificity of approximately 85% for some instruments. In patients with a clinical diagnosis of stroke, brain computed tomography or MRI is required to exclude some stroke mimics and differentiate ischemic from hemorrhagic stroke, which is key to providing appropriate therapies such as thrombolysis. In the future, plasma biomarkers may improve clinical diagnosis of stroke, but prospective studies are required to establish their utility. Clinical trials of acute stroke therapies need to ensure rapid accurate diagnosis of stroke using structured clinical assessments and appropriate imaging to achieve early treatment and avoid entry of stroke mimics into trials.

Early access to a neurologist reduces the rate of missed diagnosis in young strokes

BACKGROUND

We hypothesized that the presence of an in-house neurologist or a neurology or emergency medicine (EM) residency is associated with a lower rate of missed stroke diagnosis and a greater use of thrombolytic therapy.

METHODS

The outpatient Young Stroke registry from our academic medical center was reviewed. Patients 16 to 50 years of age who presented with ischemic stroke were included. Information on presentation, acute therapy, and missed diagnosis was obtained. The presence of an EM or neurology residency at the presenting hospital was recorded. We also assessed whether hospital teaching status in these fields affected missed diagnosis rates, the use of thrombolysis, or stroke intervention.

RESULTS

Ninety-three patients were included. Thirteen patients were misdiagnosed. In hospitals with and without a neurology residency, the missed diagnosis rate was 6.3% versus 18.0%, respectively (P=.21). Two patients were misdiagnosed in hospitals with a neurology residency, but neither had neurology consultations in the emergency department. If these cases are removed from our analysis, the rate of missed diagnosis with and without a neurology residency is 0% versus 20.6%, respectively (P=.008). Acute stroke therapy was administered in 17.9% of patients seen with an EM residency, compared to 2.7% without an EM residency (P=.046). With and without a neurology residency, acute stroke therapy was administered in 25% versus 8.2% of cases, respectively (P=.055).

CONCLUSIONS

Young adults with ischemic stroke seen at hospitals with a neurology residency had a lower missed diagnosis rate. The presence of an EM resident or a neurology teaching program was associated with a greater use of acute stroke therapies. These results support initiatives to triage young adults with suspected acute stroke to hospitals with access to neurologic expertise in the emergency department.

Avoiding misdiagnosis in patients with neurological emergencies

Approximately 5% of patients presenting to emergency departments have neurological symptoms. The most common symptoms or diagnoses include headache, dizziness, back pain, weakness, and seizure disorder. Little is known about the actual misdiagnosis of these patients, which can have disastrous consequences for both the patients and the physicians. This paper reviews the existing literature about the misdiagnosis of neurological emergencies and analyzes the reason behind the misdiagnosis by specific presenting complaint. Our goal is to help emergency physicians and other providers reduce diagnostic error, understand how these errors are made, and improve patient care.

Usefulness of CT angiography for therapeutic decision making in thrombolyzing intubated patients with suspected basilar artery thrombosis

BACKGROUND AND AIMS

Acute ischemic stroke (AIS) due to basilar artery thrombosis (BAT) causes high mortality and severe disability. Early neurological assessment and timely thrombolysis might improve outcome. BAT is difficult to diagnose due to wide spectrum of presentation and decreased conscious level. Emergency physicians often intubate BAT patients with airway compromise before arrival of stroke neurologist. We evaluated role of computerized tomography (CT) angiography (CTA) of brain and cervical arteries in early diagnosis of acute BAT in intubated patients and facilitating decision for thrombolysis.

METHODS

Consecutive AIS patients presenting between 2007 and 2009 within 6 hours of symptom onset, with sudden deterioration in conscious level and intubation before assessment by neurologist, were included. All patients underwent brain CT and CTA. Outcomes were assessed at 3 months.

RESULTS

Thrombolytic therapy, mainly intravenous tissue plasminogen activator (IV-TPA), was administered to 161 (8.4%) of 1,917 AIS patients during the study period. Acute BAT contributed 10.9% of our cohort. CTA was performed in 152 (94.4%) patients and the rest were excluded due to their impaired renal functions. Five patients (3 males, mean age 72 years) presenting with acute obtundation and airway compromise were intubated, sedated, and paralyzed before assessment by neurologist. CTA showed BAT in all. IV-TPA was initiated at 213 ± 59 minutes in 4 patients while 1 received intraarterial thrombolysis at 13 hours. There was no intracranial hemorrhage. Mean length of hospital stay was 11.8 days. Despite severe stroke at presentation, good functional recovery at 3 months (modified Rankin scale [mRS] 1) occurred in 2 patients; mRS 4 in 1, and 2 died.

CONCLUSION

In patients with BAT, intubated before assessment by neurologist, CTA might help in confirming the diagnosis and facilitating therapeutic decision making for initiating thrombolysis.

Common disorders in the neurological emergency room--experience at a tertiary care hospital

BACKGROUND

The profile of patients with neurological diseases referred to specialized emergency rooms (ER) has not been reported and it is unknown whether a setting of decentralized ERs is associated with a high number of referrals because of inappropriate admissions.

METHODS

In this prospective study, consecutive patients of a specialized neurological ER were enrolled. Data encompassed time from symptom onset to admission, discharge diagnoses, data on hospitalization and on transfers to and from other ERs.

RESULTS

Thousand seven hundred and forty-three patients were enrolled. Most common diagnoses were cerebrovascular events (26.5%), headache disorders (13%) and seizures (12.7%). Time since onset of symptoms depended on who referred the patient (P<0.001); seizure patients presented earlier than other patients (P<0.001) and 30.5% of patients with cerebrovascular events presented within 3 h after symptom onset but did not present sooner than patients with other diagnoses. In 18%, diagnoses did not match neurological disorders, 4.5% of patients suffered from cardiovascular events. Referrals to and from other ERs rarely occurred (10.3% vs. 5.9%). Only 20 patients with acute cerebrovascular events were referred via other ERs (1.1%).

CONCLUSION

A system of a specialized neurological ER can quickly clear up uncertainties in interpreting neurological symptoms. Owing to the rising number of neurological patients in ERs, more studies are urgently needed comparing the different organizational forms for emergency services.

A recognition tool for transient ischaemic attack

BACKGROUND

Scoring systems exist to assist rapid identification of acute stroke but not for the more challenging diagnosis of transient ischaemic attack (TIA).

AIM

To develop a clinical scoring system to assist with diagnosis of TIA.

METHODS

We developed and validated a clinical scoring system for identification of TIA patients. Logistic regression analysis was employed.

RESULTS

Our development cohort comprised 3216 patients. The scoring system included nine clinically useful predictive variables. After adjustment to reflect the greater seriousness of missing true TIA patients (a 2:1 cost ratio), 97% of TIA and 24% of non-TIA patients were accurately identified. Our results were confirmed during prospective validation.

CONCLUSION

This simple scoring system performs well and could be used to facilitate accurate detection of TIA.

Safety issues and concerns for the neurological patient in the emergency department

INTRODUCTION

Patient safety in our medical system has been an increasing national concern. Neurological patient safety in the emergency department (ED) has not been studied. The purpose of this article is thus to describe the issues relevant to neurological patient safety in the ED, review the current status of the literature, identify specific patient populations at risk, and suggest applicable solutions.

METHODS

Medline and PubMed literature review of key words associated with patient safety, neurological diseases, and EDs.

RESULTS

Little data can be found on overall neurological patient safety in the ED, however data for specific neurological emergencies including subarachnoid hemorrhage, stroke, status epilepticus, and head and spine trauma does exist and is reviewed.

CONCLUSIONS

Limitations in ED education and access to neurological expertise may place some patients at risk. Recommendations for improving neurological patient safety in the EDs are suggested and include a discussion on barriers to implementation.

Diagnostic accuracy of neurological problems in the emergency department

BACKGROUND

Previous studies describe significant rates of misdiagnosis of stroke, seizure and other neurological problems, but there are few studies examining diagnostic accuracy of all emergency referrals to a neurology service. This information could be useful in focusing the neurological education of physicians who assess and refer patients with neurological complaints in emergency departments.

METHODS

All neurological consultations in the emergency department at a tertiary-care teaching hospital were recorded for six months. The initial diagnosis of the requesting physician was recorded for each patient. This was compared to the initial diagnosis of the consulting neurologist and to the final diagnosis, as determined by retrospective chart review.

RESULTS

Over a six-month period, 493 neurological consultations were requested. The initial diagnosis of the requesting physician agreed with the final diagnosis in 60.4% (298/493) of cases, and disagreed or was uncertain in 35.7% of cases (19.1% and 16.6% respectively). In 3.9% of cases, the initial diagnosis of both the referring physician and the neurologist disagreed with the final diagnosis. Common misdiagnoses included neurocardiogenic syncope, peripheral vertigo, primary headache and psychogenic syndromes. Often, these were initially diagnosed as stroke or seizure.

CONCLUSIONS

Our data indicate that misdiagnosis or diagnostic uncertainty occurred in over one-third of all neurological consultations in the emergency department setting. Benign neurological conditions, such as migraine, syncope and peripheral vertigo are frequently mislabeled as seizure or stroke. Educational strategies that emphasize emergent evaluation of these common conditions could improve diagnostic accuracy, and may result in better patient care.

From the inside looking out: a view from the fishbowl

BACKGROUND

Overview of current emergency medicine practice and neurological emergencies.

CONCLUSIONS

Emergency medicine physicians review and respond to a manuscript noting the unique time pressures and diagnostic constraints in contemporary US emergency medicine practice. Definitions of error and misdiagnosis are discussed. Proposals are enumerated for practice improvement involving local feedback and educational initiatives.

Prognostic value of CT angiography in patients with suspected vertebrobasilar ischemia

BACKGROUND

The outcome of vertebrobasilar ischemia depends on the clinical presentation and the presence or absence of vascular occlusion. The aim of our study was to analyze the CT angiography (CTA) predictors of outcome in patients with suspected vertebrobasilar ischemia.

METHODS

We studied patients with suspected acute vertebrobasilar ischemia between April 2002 and January 2006 and had CTA done within 24 hours of symptom onset. We reviewed the final diagnosis and 3-month follow-up and analyzed the clinical and CTA predictors of outcome.

RESULTS

Of the 133 patients, 21(15%), 18 (13%), and 16 (12%) had occlusion of basilar artery (BA), vertebral artery (VA), and posterior cerebral artery (PCA) respectively. The final diagnosis was stroke in 98 (73.6%), transient ischemic attack (TIA) in 10 (7.5%), and nonischemic in 25 (18.8%). No vascular occlusion was seen on CTA in patients with TIA and nonischemic diagnosis. At 3-month follow-up, we found a mortality rate of 10.6% and good functional outcome in 71.4%. The predictors of death in the multivariable analysis were the presence of BA occlusion (odds ratio[OR] 6.7, 95% CI, 1.4-30.6) and baseline National Institutes of Health Stroke Scale (NIHSS) (OR 1.14, 95% CI, 1.06-1.2). When patients with basilar occlusion were excluded, the presence of VA occlusion (OR 6.5, 95% CI, 1.34-31.4), age (OR 1.09, 95% CI, 1.03-1.14), and baseline NIHSS (OR 1.1, 95% CI, 1.03-1.18) predicted poorer outcome.

CONCLUSIONS

The presence or absence of a vascular occlusion is a critical factor for prognosis in suspected acute vertebrobasilar ischemia and is correlated with the location of occlusion.

Bridging the Gap Between Primary and Specialist Care – An Integrative Model for Stroke

Stroke is a major cause of death and disability in Singapore and many parts of the world. Chronic disease management programmes allow seamless care provision across a spectrum of healthcare facilities and allow appropriate services to be brought to the stroke patient and the family. Randomised controlled trials have provided evidence for efficacious interventions. After the management of acute stroke in a stroke unit, most stable stroke patients can be sent to their family physician for continued treatment and rehabilitation supervision. Disabled stroke survivors may need added home-based services. Suitable community resources will need to be harnessed. Clinic-based stroke nurses may enhance service provision and coordination. Close collaboration between the specialist and family physician would be needed to right-site patients and also allow referrals in either direction where necessary. Barriers to integration can be surmounted by trust and improved communication. Audits would allow monitoring of care provision and quality care enhancement. The Wagner model of chronic care delivery involves self-management support, shared clinical information systems, delivery system redesign, decision support, healthcare organisation and community resources. The key and critical feature is the need for an informed, activated (or motivated) patient, working in collaboration with the specialist and family physician, and a team of nursing and allied healthcare professionals across the continuum of care. The 3-year Integrating Services and Interventions for Stroke (ISIS) project funded by the Ministry of Health will test such an integrative system. Key words: Cerebrovascular disease, Chronic disease management, Family physician, Neurologist, Stroke nurse

The use of neurovascular imaging for triaging tia and minor stroke: Implications for therapy

Nondisabling cerebrovascular events (minor stroke or transient ischemic attack) are not benign; a significant proportion of these patients will suffer a new disabling stroke or develop stroke progression in hospital, resulting in dependence or death. With the exception of the modest benefits of aspirin, there are currently no effective acute medical therapies to prevent early progression or recurrence in such patients. Early carotid revascularization appears to be the most efficacious treatment available for patients with symptomatic (> 50%) internal carotid artery stenosis. More acute treatment and acute prevention trials are needed. MRI, CT bolus techniques, and transcranial Doppler emboli detection represent tools for detection of patients at high risk for deterioration and should be incorporated into the development of effective therapies by targeting the most appropriate patients for intervention.

The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument

BACKGROUND

In patients with acute stroke, rapid intervention is crucial to maximise early treatment benefits. Stroke patients commonly have their first contact with medical staff in the emergency room (ER). We designed and validated a stroke recognition tool-the Recognition of Stroke in the Emergency Room (ROSIER) scale-for use by ER physicians.

METHODS

We prospectively collected data for 1 year (development phase) on the clinical characteristics of patients with suspected acute stroke who were admitted to hospital from the ER. We used logistic regression analysis and clinical reasoning to develop a stroke recognition instrument for application in this setting. Patients with suspected transient ischaemic attack (TIA) with no symptoms or signs when assessed in the ER were excluded from the analysis. The instrument was assessed using the baseline 1-year dataset and then prospectively validated in a new cohort of ER patients admitted over a 9-month period.

FINDINGS

In the development phase, 343 suspected stroke patients were assessed (159 stroke, 167 non-stroke, 32 with TIA [17 with symptoms when seen in ER]). Common stroke mimics were seizures (23%), syncope (23%), and sepsis (10%). A seven-item (total score from -2 to +5) stroke recognition instrument was constructed on the basis of clinical history (loss of consciousness, convulsive fits) and neurological signs (face, arm, or leg weakness, speech disturbance, visual field defect). When internally validated at a cut-off score greater than zero, the instrument showed a diagnostic sensitivity of 92%, specificity of 86%, positive predictive value (PPV) of 88%, and negative predictive value (NPV) of 91%. Prospective validation in 173 consecutive suspected stroke referrals (88 stroke, 59 non-stroke, 26 with TIA [13 with symptoms]) showed sensitivity of 93% (95% CI 89-97), specificity 83% (77-89), PPV 90% (85-95), and NPV 88% (83-93). The ROSIER scale had greater sensitivity than existing stroke recognition instruments in this population.

INTERPRETATION

The ROSIER scale was effective in the initial differentiation of acute stroke from stroke mimics in the ER. Introduction of the instrument improved the appropriateness of referrals to the stroke team.

Misdiagnosis of stroke in tissue plasminogen activator–treated patients

STUDY OBJECTIVE

Misdiagnosis of acute ischemic stroke is a risk inherent in treating patients with acute deficits, yet few data exist on the problem. We report an evaluation of emergency department misdiagnoses in patients treated with tissue plasminogen activator for acute ischemic stroke.

METHODS

We conducted an observational study of 151 consecutive patients treated without an acute stroke team. Initial diagnosis was compared with interim and hospital discharge diagnoses. Separate analyses were performed for patients without a final diagnosis of acute ischemic stroke and for those without a final diagnosis of either acute ischemic stroke or transient ischemic attack, combined.

RESULTS

Ten of 151 patients (7%; 95% confidence interval [CI] 3% to 12%) had final diagnoses that did not include acute ischemic stroke. Six of 151 (4%; 95% CI 1% to 8%) had a final diagnosis other than acute ischemic stroke or transient ischemic attack (conversion disorder [4], complex migraine [1], and Todd's paralysis [1]). These "stroke mimics" had no intracranial hemorrhage (0%; 95% CI 0% to 31%), had less disability at discharge (modified Rankin Scale score mean+/-SD, 2.2+/-1.3 versus 3.2+/-1.8), and were younger (mean age+/-SD, 47+/-21 years versus 68+/-15 years) than patients with acute ischemic stroke or transient ischemic attack. An additional 4 (3%) patients had interim diagnoses other than acute ischemic stroke, all subsequently changed to acute ischemic stroke after magnetic resonance imaging or computed tomography.

CONCLUSION

These data show that in a 4-hospital system without an acute stroke team, thrombolytic treatment of patients with diagnoses mimicking stroke was infrequent, and hemorrhagic complications did not occur in any patients without an acute ischemic stroke. However, because the number of mimics was small, safety cannot be ensured with statistical confidence.

Emergent CT evaluation of stroke

The rapid neuroimaging of a patient that has suffered a stroke is a critical preamble to the emergent initiation of thrombolytic therapy. Emergency physicians must be familiar with normal brain structures as they appear on CT, as well as common stroke patterns. The more facile emergency physicians are at interpreting the head CT, the better they can communicate with consulting specialists and deliver prompt care to patients that present with neurologic emergencies.