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Kumar M, Beyea S, Hu S, Kamal N. Exploring the role of in-patient magnetic resonance imaging use among admitted ischemic stroke patients in improving patient outcomes and reducing healthcare resource utilization. Front Neurol 2024; 15:1305514. [PMID: 38562429 PMCID: PMC10983768 DOI: 10.3389/fneur.2024.1305514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Purpose Despite the diagnostic and etiological significance of in-patient MRI in ischemic stroke (IS), its utilization is considered resource-intensive, expensive, and thus limiting feasibility and relevance. This study investigated the utilization of in-patient MRI for IS patients and its impact on patient and healthcare resource utilization outcomes. Methods This retrospective registry-based study analyzed 1,956 IS patients admitted to Halifax's QEII Health Centre between 2015 and 2019. Firstly, temporal trends of MRI and other neuroimaging utilization were evaluated. Secondly, we categorized the cohort into two groups (MRI vs. No MRI; in addition to a non-contrast CT) and investigated adjusted differences in patient outcomes at admission, discharge, and post-discharge using logistic regression. Additionally, we analyzed healthcare resource utilization using Poisson log-linear regression. Furthermore, patient outcomes significantly associated with MRI use underwent subgroup analysis for stroke severity (mild stroke including transient ischemic attack vs. moderate and severe stroke) and any acute stage treatment (thrombolytic or thrombectomy or both vs. no treatment) subgroups, while using an age and sex-adjusted logistic regression model. Results MRI was used in 40.5% patients; non-contrast CT in 99.3%, CT angiogram in 61.8%, and CT perfusion in 50.3%. Higher MRI utilization was associated with male sex, younger age, mild stroke, wake-up stroke, and no thrombolytic or thrombectomy treatment. MRI use was independently associated with lower in-hospital mortality (adjusted OR, 0.23; 95% CI, 0.15-0.36), lower symptomatic neurological status changes (0.64; 0.43-0.94), higher home discharge (1.32; 1.07-1.63), good functional outcomes at discharge (mRS score 0-2) (1.38; 1.11-1.72), lower 30-day stroke re-admission rates (0.48; 0.26-0.89), shorter hospital stays (regression coefficient, 0.92; 95% CI, 0.90-0.94), and reduced direct costs of hospitalization (0.90; 0.89-0.91). Subgroup analysis revealed significantly positive association of MRI use with most patient outcomes in moderate and severe strokes subgroup and non-acutely treated subgroup. Conversely, outcomes in mild strokes (including TIAs) subgroup and acute treatment subgroup were comparable regardless of MRI use. Conclusion A substantial proportion of admitted IS patients underwent MRI, and MRI use was associated with improved patient outcomes and reduced healthcare resource utilization. Considering the multifactorial nature of IS patient outcomes, further randomized controlled trials are suggested to investigate the role of increased MRI utilization in optimizing in-patient IS management.
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Affiliation(s)
- Mukesh Kumar
- Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
| | - Steven Beyea
- Department of Diagnostic Radiology, Dalhousie University, Halifax, NS, Canada
- IWK Health, Halifax, NS, Canada
| | - Sherry Hu
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
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2
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Nair R, Khan K, Stang JM, Halabi ML, Youngson E, Alrohimi A, Shuaib A. Thrombolysis in Stroke Mimics: Comprehensive Stroke Centers vs Telestroke Sites. Can J Neurol Sci 2023; 50:838-844. [PMID: 36453234 DOI: 10.1017/cjn.2022.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Hyperacute treatment of acute stroke may lead to thrombolysis in stroke mimics (SM). Our aim was to determine the frequency of thrombolysis in SM in primary stroke centers (PSC) dependent on telestroke versus comprehensive stroke centers (CSC). METHOD Retrospective review of prospectively collected data from the Quality improvement and Clinical Research (QuICR) registry, the Discharge Abstract Database (DAD), and The National Ambulatory Care Reporting System (NACRS) of consecutive patients treated with intravenous thrombolysis for acute ischemic stroke in Alberta (Canada) from April 2016 to March 2021. RESULT A total of 2471 patients who received thrombolysis were included. Linking the QuICR registry to DAD 169 (6.83%) patients were identified as SM; however, on our review of the records, only 112 (4.53%) were actual SM. SMs were younger with a mean age of 61.66 (±16.15) vs 71.08 (±14.55) in stroke. National Institute of Health Stroke Scale was higher in stroke with a median (IQR) of 10 (5-17) vs 7 (5-10) in SM. Only one patient (0.89 %) in SM groups had a small parenchymal hemorrhage versus 155 (6.57%) stroke patients had a parenchymal hemorrhage. There was no death among patients of thrombolysed SM during hospitalization versus 276 (11.69%) in stroke. There was no significant difference in the rate of SM among thrombolysed patients between PSC 27 (5.36%) versus CSC 85 (4.3%) (P = 0.312). The most responsible diagnosis of SM was migraine/migraine equivalent, functional disorder, seizure, and delirium. CONCLUSION The diagnosis of SM may not always be correct when the information is extracted from databases. The rate of thrombolysis in SM via telestroke is similar to treatment in person at CSC.
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Affiliation(s)
- Radhika Nair
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Khurshid Khan
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | | | | | | | - Anas Alrohimi
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
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Pu MJ, Yu JL, Hu X, Deng L, Chen C, Lv XN, Li ZQ, Wang ZJ, Xie P, Li Q. Incidence, characteristics and outcome of post-stroke recrudescence in the Chinese population: a single-centre observational study. BMJ Open 2023; 13:e068878. [PMID: 37709315 PMCID: PMC11148692 DOI: 10.1136/bmjopen-2022-068878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVES The aim of our observational study was to investigate the incidence, clinical characteristics and outcome of post-stroke recrudescence (PSR) in the Chinese population. DESIGN AND SETTING Single-centre prospective observational study in China. PARTICIPANTS A total of 1114 patients who had a suspected stroke were prospectively screened from October 2020 to February 2022. OUTCOME MEASURES The primary outcome was the proportion of patients with functional independence defined as a score of 0-2 on the modified Rankin Scale (mRS) at 3 months. Secondary outcomes were: early neurological improvement (ENI), defined as a National Institutes of Health Stroke Scale (NIHSS) score of 0 or an improvement of ≥2 points from admission at 24 hours; mortality within 3 months; stroke recurrence within 3 months and length of stay in hospital. RESULTS A total of 959 patients with cerebral infarction and 30 patients without an available magnetic resonance imaging (MRI) scan were excluded. Among the 125 included patients, 27 cases of PSR (2.4%), 50 cases of transient ischaemic attack (TIA) (4.5%) and 48 cases of stroke mimics (SMs) (4.3%) were identified. A higher frequency of infection at admission (22.2% vs 2%, p=0.007) was observed in patients with PSR compared with patients with TIA, and a lower proportion of functional independence at 3 months (80% vs 98%, p=0.015) was seen. Patients with TIA had a higher frequency of ENI compared with patients with PSR and SMs (98% vs 59.3%, p<0.001; 98% vs 52.1%, p<0.001). Patients with PSR exhibited a higher frequency of grade 2 Fazekas deep white matter hyperintensity compared with those with SMs (33.3% vs 8.3%, p=0.010). CONCLUSIONS PSR is not uncommon in patients presenting with stroke symptoms and can be distinguished from TIA and SMs based on a combination of clinical features and trigger in the Chinese population. The neurological deficits of patients with PSR often resolve within several days following the resolution of the trigger.
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Affiliation(s)
- Ming-Jun Pu
- Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jia-Lun Yu
- Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Hu
- Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lan Deng
- Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chu Chen
- Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin-Ni Lv
- Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zuo-Qiao Li
- Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zi-Jie Wang
- Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peng Xie
- Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Li
- Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Macias-Gómez A, Suárez-Pérez A, Rodríguez-Campello A, Giralt-Steinhauer E, Moreira A, Guisado-Alonso D, Capellades J, Fernández-Pérez I, Jiménez-Conde J, Rey L, Jiménez-Balado J, Roquer J, Ois Á, Cuadrado-Godia E. Factors associated with migraine aura mimicking stroke in code stroke. Neurol Sci 2023; 44:2113-2120. [PMID: 36749530 DOI: 10.1007/s10072-023-06641-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/23/2023] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Migraine with aura (MA) is a frequent stroke simulator that can lead to erroneous diagnosis and subsequent unnecessary acute or secondary prevention treatments. We analyzed clinical and laboratory data of migraine with aura and ischemic stroke patients to detect differences that could help in the diagnosis. METHODS Retrospective analysis of a consecutive register of code strokes between January 2005 and June 2020. Diagnosis of ischemic stroke or MA was collected. Multivariable logistic regression analyses were performed to test associations between clinical and blood data with ischemic stroke. RESULTS Of 3140 code strokes, 2424 (77.2%) were ischemic strokes and 34 (1.1%) were MA. Migraine cases were younger, more frequently females and with lower prevalence of vascular risk factors. Initial NIHSS was lower in MA cases, but no differences were seen in fibrinolysis rate (30%). Blood test showed lower levels of glucose, D-dimer, and fibrinogen in MA cases. Multivariable model showed and independent association for ischemic stroke with age [OR, (95%CI): 1.09, (1.07-1.12, p < 0.001], male sex [OR, (95%CI): 4.47, (3.80-5.13), p < 0.001], initial NIHSS [OR, (95%CI): 1.21, (1.07-1.34), p < 0.01], and fibrinogen levels [OR, (95%CI): 1.01, (1.00-1.01), p < 0.05]. A model including sex male OR: 3.55 [2.882; 4.598], p < 0.001, and cutoff points (age > 65, OR: 7.953 [7.256; 8.649], p < 0.001, NIHSS > 6, OR: 3.740 [2.882; 4.598], p < 0.01, and fibrinogen > 400 mg/dL, OR: 2.988 [2.290; 3.686], p < 0.01) showed a good global discrimination capability AUC = 0.89 (95%CI: 0.88-0.94). CONCLUSIONS In code stroke, a model including age, sex, NIHSS, and fibrinogen showed a good discrimination capability to differentiate between MA and Ischemic stroke. Whether these variables can be implemented in a diagnostic rule should be tested in future studies.
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Affiliation(s)
- Adrià Macias-Gómez
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Antoni Suárez-Pérez
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Ana Rodríguez-Campello
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Eva Giralt-Steinhauer
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain. .,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain.
| | - Antía Moreira
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain
| | - Daniel Guisado-Alonso
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain
| | - Jaume Capellades
- Neuroradiology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain
| | - Isabel Fernández-Pérez
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Jordi Jiménez-Conde
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Lucía Rey
- Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Joan Jiménez-Balado
- Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Jaume Roquer
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Ángel Ois
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Elisa Cuadrado-Godia
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
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5
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Høllesli LJ, Ajmi SC, Kurz MW, Tysland TB, Hagir M, Dalen I, Qvindesland SA, Ersdal H, Kurz KD. Simulation-based team-training in acute stroke: Is it safe to speed up? Brain Behav 2022; 12:e2814. [PMID: 36416494 PMCID: PMC9759129 DOI: 10.1002/brb3.2814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 10/01/2022] [Accepted: 10/18/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In acute ischemic stroke (AIS), rapid treatment with intravenous thrombolysis (IVT) is crucial for good clinical outcome. Weekly simulation-based team-training of the stroke treatment team was implemented, resulting in faster treatment times. The aim of this study was to assess whether this time reduction led to a higher proportion of stroke mimics (SMs) among patients who received IVT for presumed AIS, and whether these SM patients were harmed by intracranial hemorrhage (ICH). METHODS All suspected AIS patients treated with IVT between January 1, 2015 and December 31, 2020 were prospectively registered. In 2017, weekly in situ simulation-based team-training involving the whole stroke treatment team was introduced. To analyze possible unintended effects of simulation training, the proportion of SMs among patients who received IVT for presumed AIS were identified by clinical and radiological evaluation. Additionally, we identified the extent of symptomatic ICH (sICH) in IVT-treated SM patients. RESULTS From 2015 to 2020, 959 patients were treated with IVT for symptoms of AIS. After introduction of simulation training, the proportion of patients treated with IVT who were later diagnosed as SMs increased significantly (15.9% vs. 24.4%, p = .003). There were no ICH complications in the SM patients treated before, whereas two SM patients suffered from asymptomatic ICH after introduction of simulation training (p = 1.0). When subgrouping SMs into prespecified categories, only the group diagnosed with peripheral vertigo increased significantly (2.5% vs. 8.6%, p < .001). CONCLUSIONS Simulation training of the acute stroke treatment team was associated with an increase in the proportion of patients treated with IVT for a suspected AIS who were later diagnosed with peripheral vertigo. The proportion of other SM groups among IVT-treated patients did not change significantly. No sICH was detected in IVT-treated SM patients.
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Affiliation(s)
- Liv Jorunn Høllesli
- Stavanger Medical Imaging Laboratory (SMIL), Department of Radiology, Stavanger University Hospital, Stavanger, Norway.,Department of Electrical Engineering and Computer Science, University of Stavanger, Stavanger, Norway
| | - Soffien Chadli Ajmi
- Neurology Research Group, Department of Neurology, Stavanger University Hospital, Stavanger, Norway.,Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Martin W Kurz
- Neurology Research Group, Department of Neurology, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Thomas Bailey Tysland
- Neurology Research Group, Department of Neurology, Stavanger University Hospital, Stavanger, Norway
| | - Morten Hagir
- Department of Radiology, Hospital of Southern Norway Kristiansand, Kristiansand, Norway
| | - Ingvild Dalen
- Department of Research, Section of Biostatistics, Stavanger University Hospital, Stavanger, Norway
| | - Sigrun Anna Qvindesland
- Department of Research, Simulation Section, Stavanger University Hospital, Stavanger, Norway
| | - Hege Ersdal
- Critical Care and Anesthesiology Research Group, Stavanger University Hospital, Stavanger, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Kathinka D Kurz
- Stavanger Medical Imaging Laboratory (SMIL), Department of Radiology, Stavanger University Hospital, Stavanger, Norway.,Department of Electrical Engineering and Computer Science, University of Stavanger, Stavanger, Norway
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Garg R. Methodological survey of missing outcome data in an alteplase for ischemic stroke meta-analysis. Acta Neurol Scand 2022; 146:252-257. [PMID: 35652287 PMCID: PMC9541760 DOI: 10.1111/ane.13656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/29/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Recent national guidelines recommend alteplase treatment for ischemic stroke within 4.5 h of symptom-onset based on meta-analyses of randomized controlled clinical trials (RCT). A detailed description of missing outcome data (MOD) due to participant loss to follow-up has never been published. The objective of this study was to perform a methodlogical survey on missing outcome data in an alteplase for ischemic stroke meta-analysis. MATERIALS AND METHODS A methodological survey was performed on a chosen meta-analysis of alteplase for ischemic stroke RCTs that most closely aligns with recent national guideline recommendations. Data were collected to assess the number of participants lost to follow-up; differential lost to follow-up between allocation groups; baseline characteristics of those lost to follow-up; and the imputation methods used by individual trials and the chosen meta-analysis. The number of participants lost to follow-up was compared with the fragility index; and repeated for individually positive RCTs in the meta-analysis. RESULTS The methodological survey revealed a substantial degree of missing information regarding MOD in the chosen meta-analysis and in individual RCTs. Single imputation was exclusively used in all RCTs and in the meta-analysis. The number of participants lost to follow-up was greater than the fragility index in the chosen meta-analysis and individually positive component RCTs suggesting that MOD may impact the direction of the reported effect or effect size. CONCLUSION This methodological survey of an alteplase for ischemic stroke meta-analysis revealed MOD may be an important source of unrecognized bias. This survey highlights the need for sensitivity analyses using more robust methods of imputation.
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Affiliation(s)
- Ravi Garg
- Division of Neurocritical Care, Department of Neurology Loyola University Chicago Stritch School of Medicine Maywood Illinois USA
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H. Buck B, Akhtar N, Alrohimi A, Khan K, Shuaib A. Stroke mimics: incidence, aetiology, clinical features and treatment. Ann Med 2021; 53:420-436. [PMID: 33678099 PMCID: PMC7939567 DOI: 10.1080/07853890.2021.1890205] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022] Open
Abstract
Mimics account for almost half of hospital admissions for suspected stroke. Stroke mimics may present as a functional (conversion) disorder or may be part of the symptomatology of a neurological or medical disorder. While many underlying conditions can be recognized rapidly by careful assessment, a significant proportion of patients unfortunately still receive thrombolysis and admission to a high-intensity stroke unit with inherent risks and unnecessary costs. Accurate diagnosis is important as recurrent presentations may be common in many disorders. A non-contrast CT is not sufficient to make a diagnosis of acute stroke as the test may be normal very early following an acute stroke. Multi-modal CT or magnetic resonance imaging (MRI) may be helpful to confirm an acute ischaemic stroke and are necessary if stroke mimics are suspected. Treatment in neurological and medical mimics results in prompt resolution of the symptoms. Treatment of functional disorders can be challenging and is often incomplete and requires early psychiatric intervention.
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Affiliation(s)
- Brian H. Buck
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
| | - Naveed Akhtar
- Neurological Institute, Hamad Medical Corporation, Doha, Qatar
| | - Anas Alrohimi
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
- Department of Medicine (Neurology), King Saud University, Riyadh, Saudi Arabia
| | - Khurshid Khan
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
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8
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Sidorov E, Iser C, Kapoor N, Ray B, Chainakul J, Xu C, Alexandrov AV, Gordon DL. Criteria for Emergency Brain MRI During Stroke-Alert. J Stroke Cerebrovasc Dis 2021; 30:105890. [PMID: 34107417 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/29/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Intravenous (IV) tissue plasminogen activator (tPA) should be given to patients with acute ischemic stroke (AIS) and avoided in stroke mimics (SM). Select use of emergency brain magnetic resonance imaging (eMRI-brain) in stroke-alerts aids diagnosis, but accepted utilization criteria for eMRI-brain do not currently exist. We developed criteria for eMRI-brain and report the yield of eMRI-brain in stroke-alert patients. MATERIALS AND METHODS We developed three history-based criteria for performing eMRI-brain during stroke-alerts: (1) history of previous similar deficits, (2) change in consciousness at onset of symptoms, (3) symptom presentation consistent with migraine aura. We then performed a retrospective chart review of patients who presented as a stroke-alert over a 5-year period and determined how these criteria affected administration of IV tPA to AIS and SM patients. RESULTS Among 3,512 stroke-alerts, 230 (8.1%) patients met our criteria for eMRI-brain exams: 217 (92.6%) had SM and 17 (7.4%) had AIS. Our IV tPA decision-making analysis showed that based on eMRI-brain IV tPA was less frequently administered to SM patients (PCC-0.841, p=0.036) with less failures to administer IV tPA to patients with AIS (PCC -0.907, p-value=0.013, Pearson correlation coefficient). No patients became ineligible for IV tPA due to MRI-related time delays. CONCLUSIONS Our history based criteria for performing eMRI-brain during stroke-alerts show a high yield of stroke mimics. Selective eMRI-brain improves decision-making accuracy regarding IV tPA administration.
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Affiliation(s)
- Evgeny Sidorov
- Department of Neurology, University of Oklahoma Health Sciences Center, 920 S.L.Young Blvd #2040, Oklahoma City, OK 73104, USA; Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, 1100 N Lindsay Ave., Oklahoma City, OK 73104, USA.
| | - Courtney Iser
- Department of Neurology, University of Oklahoma Health Sciences Center, 920 S.L.Young Blvd #2040, Oklahoma City, OK 73104, USA
| | - Nidhi Kapoor
- University of Arkansas, Department of Neurology 4301 W. Markham St., Slot 500 Little Rock, AR 72205, USA
| | - Bappaditya Ray
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX 75390, USA
| | - Juliane Chainakul
- Department of Neurology, University of Oklahoma Health Sciences Center, 920 S.L.Young Blvd #2040, Oklahoma City, OK 73104, USA
| | - Chao Xu
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, 801 N.E. 13th Street, Oklahoma City, OK 73104 USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, 847 Monroe Ave Suite M226, Memphis, TN 38163
| | - David Lee Gordon
- Department of Neurology, University of Oklahoma Health Sciences Center, 920 S.L.Young Blvd #2040, Oklahoma City, OK 73104, USA; Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, 1100 N Lindsay Ave., Oklahoma City, OK 73104, USA
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9
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Yuan CX, Ruan YT, Zeng YY, Cheng HR, Cheng QQ, Chen YB, He WL, Huang GQ, He JC. Liver Fibrosis Is Associated With Hemorrhagic Transformation in Patients With Acute Ischemic Stroke. Front Neurol 2020; 11:867. [PMID: 33013622 PMCID: PMC7512114 DOI: 10.3389/fneur.2020.00867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/07/2020] [Indexed: 12/05/2022] Open
Abstract
Background: Hemorrhagic transformation (HT) is a frequent, often asymptomatic event that occurs after acute ischemic stroke (AIS). Liver fibrosis, usually subclinical, is common and crucial in the development of liver disease. We aimed to investigate the association between liver fibrosis and HT in patients with AIS. Methods: We performed a single-center and retrospective study. A total of 185 consecutive participants with HT and 199 age- and sex-matched stroke patients without HT were enrolled in this study. We calculated one validated fibrosis index—Fibrosis-4 (FIB-4) score—to assess the extent of liver fibrosis. HT was detected by routine CT or MRI and was radiologically classified as hemorrhagic infarction type 1 or 2 or parenchymal hematoma type 1 or 2. HT was also classified into asymptomatic or symptomatic. We used logistic regression models adjusted for previously established risk factors to assess the risks for HT. Results: The median FIB-4 score was significantly higher among patients who developed HT than among those without HT, whereas standard hepatic assays were largely normal. Patients were assigned to groups of high FIB-4 score and low FIB-4 score based on the optimal cutoff value. Compared with the subjects in the low-FIB-4-score group, incidence of HT for the high-FIB-4-score group was significantly higher. After adjustment for potential confounders, the patients with high FIB-4 score had 3.461-fold risk of HT in AIS compared to the patients with low FIB-4 score [odds ratio, 3.461 (95% CI, 1.404–8.531)]. Conclusion: Liver fibrosis, measured by FIB-4 score, was independently associated with the risk of HT in AIS patients.
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Affiliation(s)
- Cheng-Xiang Yuan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi-Ting Ruan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ya-Ying Zeng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hao-Ran Cheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qian-Qian Cheng
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Yun-Bin Chen
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wei-Lei He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Gui-Qian Huang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jin-Cai He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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10
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Abstract
Purpose of review Imaging constitutes one of the key pillars in the diagnostic workup after a first seizure as well as for the presurgical workup in epilepsy. The role of imaging in emergency situations, mainly to support the adequate diagnosis, as well as its role in planning of noninvasive image-guided therapies is less well established. Here, we provide an overview on peri-ictal imaging findings to support differential diagnosis in emergency situations and describe recent attempts toward minimal invasive therapy in the treatment of epilepsy and its comorbidities based on a combination of imaging techniques with ultrasound. Recent findings Peri-ictal perfusion changes can differentiate ictal stroke mimics from acute ischemic stroke if focal areas of increased perfusion are depicted by computed tomography or MRI. Postictal perfusion patterns in patients with persisting neurological symptoms are frequently normal and do not reach enough diagnostic sensitivity to differentiate between stroke and its mimics. Noninvasive magnetic resonance-techniques as arterial spin labeling may provide a higher sensitivity, especially in combination with diffusion-weighted and susceptibility-weighted MRI. Imaging guided focused ultrasound (FUS) bears the potential to ablate epileptogenic tissue and allows suppression of epileptic activity. Imaging guided blood–brain-barrier opening with FUS offers new options for local drug administration. Summary MRI should be considered the method of choice in the differential diagnosis of peri-ictal imaging findings and their differential diagnosis. A combination of various MRI techniques with FUS opens new avenues for treatment of epilepsy.
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11
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Popkirov S, Stone J, Buchan AM. Functional Neurological Disorder: A Common and Treatable Stroke Mimic. Stroke 2020; 51:1629-1635. [PMID: 32295508 DOI: 10.1161/strokeaha.120.029076] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Stoyan Popkirov
- From the Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Germany (S.P.).,Wissenschaftskolleg zu Berlin-Institute for Advanced Study, Germany (S.P., A.M.B.)
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, United Kingdom (J.S.)
| | - Alastair M Buchan
- Wissenschaftskolleg zu Berlin-Institute for Advanced Study, Germany (S.P., A.M.B.).,Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, United Kingdom (A.M.B.)
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12
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Liberman AL, Antoniello D, Tversky S, Fara MG, Zhang C, Gurin L, Rostanski SK. Multiple Administrations of Intravenous Thrombolytic Therapy to a Stroke Mimic. J Emerg Med 2019; 58:e133-e136. [PMID: 31806434 DOI: 10.1016/j.jemermed.2019.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/07/2019] [Accepted: 10/13/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients who present emergently with focal neurological deficits concerning for acute ischemic stroke can be extremely challenging to diagnose and treat. Unnecessary administration of thrombolytics to potential stroke patients whose symptoms are not caused by an acute ischemic stroke-stroke mimics-may result in patient harm, although the overall risk of hemorrhagic complications among stroke mimics is low. CASE REPORT We present a case of a stroke mimic patient with underlying psychiatric disease who was treated with intravenous alteplase on four separate occasions in four different emergency departments in the same city. Although he did not suffer hemorrhagic complications, this case highlights the importance of rapid exchange of health information across institutions to improve diagnostic quality and safety. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Increased awareness of stroke mimics by emergency physicians may improve diagnostic safety for a subset of high-risk patients. Establishing rapid cross-institutional communication pathways that are integrated into provider's workflows to convey essential patient health information has potential to improve stroke diagnostic decision-making and thus represents an important topic for health systems research in emergency medicine.
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Affiliation(s)
- Ava L Liberman
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Daniel Antoniello
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Steven Tversky
- Department of Neurology, Winthrop-University Hospital, Mineola, New York
| | - Michael G Fara
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cen Zhang
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Lindsey Gurin
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Sara K Rostanski
- Department of Neurology, New York University School of Medicine, New York, New York
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13
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Liberman AL, Choi HJ, French DD, Prabhakaran S. Is the Cost-Effectiveness of Stroke Thrombolysis Affected by Proportion of Stroke Mimics? Stroke 2019; 50:463-468. [PMID: 30572813 DOI: 10.1161/strokeaha.118.022857] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Differentiating ischemic stroke patients from stroke mimics (SM), nonvascular conditions which simulate stroke, can be challenging in the acute setting. We sought to model the cost-effectiveness of treating suspected acute ischemic stroke patients before a definitive diagnosis could be made. We hypothesized that we would identify threshold proportions of SM among suspected stroke patients arriving to an emergency department above which administration of intravenous thrombolysis was no longer cost-effective. Methods- We constructed a decision-analytic model to examine various emergency department thrombolytic treatment scenarios. The main variables were proportion of SM to true stroke patients, time from symptom onset to treatment, and complication rates. Costs, reimbursement rates, and expected clinical outcomes of ischemic stroke and SM patients were estimated from published data. We report the 90-day incremental cost-effectiveness ratio of administering intravenous thrombolysis compared with no acute treatment from a healthcare sector perspective, as well as the cost-reimbursement ratio from a hospital-level perspective. Cost-effectiveness was defined as a willingness to pay <$100 000 USD per quality adjusted life year gained and high cost-reimbursement ratio was defined as >1.5. Results- There was an increase in incremental cost-effectiveness ratios as the proportion of SM cases increased in the 3-hour time window. The threshold proportion of SM above which the decision to administer thrombolysis was no longer cost-effective was 30%. The threshold proportion of SM above which the decision to administer thrombolysis resulted in high cost-reimbursement ratio was 75%. Results were similar for patients arriving within 0 to 90 minutes of symptom onset as compared with 91 to 180 minutes but were significantly affected by cost of alteplase in sensitivity analyses. Conclusions- We identified thresholds of SM above which thrombolysis was no longer cost-effective from 2 analytic perspectives. Hospitals should monitor SM rates and establish performance metrics to prevent rising acute stroke care costs and avoid potential patient harms.
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Affiliation(s)
- Ava L Liberman
- From the Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY (A.L.L.)
| | - Ho-Jun Choi
- McCormick School of Engineering and Applied Science, Northwestern University. Evanston, IL (H.-J.C.)
| | - Dustin D French
- Department of Ophthalmology and Center for Healthcare Studies (D.D.F.), Feinberg School of Medicine, Northwestern University, Chicago, IL.,Veterans Affairs Health Services Research and Development Service, Chicago, Illinois (D.D.F.)
| | - Shyam Prabhakaran
- Department of Neurology (S.P.), Feinberg School of Medicine, Northwestern University, Chicago, IL
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14
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Lin CH, Hsu KC, Johnson KR, Luby M, Fann YC. Applying density-based outlier identifications using multiple datasets for validation of stroke clinical outcomes. Int J Med Inform 2019; 132:103988. [PMID: 31590140 DOI: 10.1016/j.ijmedinf.2019.103988] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/20/2019] [Accepted: 10/01/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Clinicians commonly use the modified Rankin Scale (mRS) and the Barthel Index (BI) to measure clinical outcome after stroke. These are potential targets in machine learning models for stroke outcome prediction. Therefore, the quality of the measurements is crucial for training and validation of these models. The objective of this study was to apply and evaluate density-based outlier detection methods for identifying potentially incorrect measurements in multiple large stroke datasets to assess the measurement quality. METHOD We applied three density-based outlier detection methods including density-based spatial clustering of applications (DBSCAN), hierarchical DBSCAN (HDBSCAN) and local outlier factor (LOF) based on a large dataset obtained from a nationwide prospective stroke registry in Taiwan. The testing of each method was done by using four different NINDS funded stroke datasets. RESULT The DBSCAN achieved a high performance across all mRS values where the highest average accuracy was 99.2 ± 0.7 at mRS of 4 and the lowest average accuracy was 92.0 ± 4.6 at mRS of 3. The LOF also achieved similar performance, however, the HDBSCAN with default parameters setting required further tuning improvement. CONCLUSION The density-based outlier detection methods were proven to be promising for validation of stroke outcome measures. The outlier detection algorithm developed from a large prospective registry dataset was effectively applied in four different NINDS stroke datasets with high performance results. The tool developed from this detection algorithm can be further applied to real world datasets to increase the data quality in stroke outcome measures.
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Affiliation(s)
- Ching-Heng Lin
- Center for Information Technology, National Institutes of Health, Bethesda, MD, United States
| | - Kai-Cheng Hsu
- Bioinformatics Section, National Institute of Neurological Disorder and Stroke, National Institutes of Health, Bethesda, MD, United States; Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kory R Johnson
- Bioinformatics Section, National Institute of Neurological Disorder and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Marie Luby
- Stroke Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Yang C Fann
- Bioinformatics Section, National Institute of Neurological Disorder and Stroke, National Institutes of Health, Bethesda, MD, United States.
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15
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Vogrig A, Bernardini A, Gigli GL, Corazza E, Marini A, Segatti S, Fabris M, Honnorat J, Valente M. Stroke-Like Presentation of Paraneoplastic Cerebellar Degeneration: a Single-Center Experience and Review of the Literature. CEREBELLUM (LONDON, ENGLAND) 2019; 18:976-982. [PMID: 31463826 DOI: 10.1007/s12311-019-01075-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Paraneoplastic cerebellar degeneration (PCD) is usually thought to have a subacute progression over several weeks. We report herein incidence and clinical features of hyperacute onset PCD, a vertebrobasilar stroke mimic. We performed a retrospective analysis of all suspected PCD cases referred to the Udine University Hospital between 2009 and 2017. Our center provides the only neuroimmunology laboratory for three provinces of the Friuli-Venezia Giulia region, Italy (983,190 people as of January 1, 2017). Inclusion criteria were (1) abrupt onset of neurological symptoms; (2) initial consideration of a vascular etiology; (3) final diagnosis of "definite PCD." We also carried out a systematic review of the literature in order to identify previous stroke-like PCD cases. Between 2009 and 2017, 24 patients received a final diagnosis of PCD. The age-standardized incidence rate of PCD was 0.22/100,000 person-years. Two cases (8.3%) had a stroke-like onset, with an incidence of 0.02/100,000 person-years. Additionally, 10 previously reported stroke-like PCD cases were identified. Among all cases (n = 12), 67% were female; median age was 51 years (range, 22-69). An associated cancer was discovered in all cases. Brain imaging was normal in most (75%) of the patients. Cerebrospinal fluid (CSF) analysis showed inflammatory alterations in 73% of the cases. Cancer treatment was more effective than immunotherapy in improving the neurological syndrome. Typical patients with hyperacute PCD are middle-aged women with normal brain imaging, inflammatory markers in CSF, and cancer. Surgery of the underlying cancer is probably the best treatment. PCD must be considered in the differential diagnosis of acute-onset ataxia and/or vertigo.
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Affiliation(s)
- Alberto Vogrig
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Piazzale Santa Maria della Misericordia, 15, 33010, Udine, Italy.
- French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon University Hospital, Lyon, France.
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France.
- University Claude Bernard Lyon 1, University of Lyon, Lyon, France.
| | - Andrea Bernardini
- Neurology Unit, Department of Medicine (DAME), University of Udine Medical School, Udine, Italy
| | - Gian Luigi Gigli
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Piazzale Santa Maria della Misericordia, 15, 33010, Udine, Italy
- Neurology Unit, Department of Medicine (DAME), University of Udine Medical School, Udine, Italy
- Department of Mathematics, Informatics and Physics (DMIF), University of Udine, Udine, Italy
| | - Elisa Corazza
- Neurology Unit, Department of Medicine (DAME), University of Udine Medical School, Udine, Italy
| | - Alessandro Marini
- Neurology Unit, Department of Medicine (DAME), University of Udine Medical School, Udine, Italy
| | - Samantha Segatti
- Neurology Unit, Department of Medicine (DAME), University of Udine Medical School, Udine, Italy
| | - Martina Fabris
- Institute of Clinical Pathology, Department of Laboratory Medicine, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Jérôme Honnorat
- French Reference Center on Paraneoplastic Neurological Syndrome and Autoimmune Encephalitis, Hospital for Neurology and Neurosurgery Pierre Wertheimer, Lyon University Hospital, Lyon, France
- SynatAc Team, NeuroMyoGene Institute, INSERM U1217/CNRS UMR5310, Lyon, France
- University Claude Bernard Lyon 1, University of Lyon, Lyon, France
| | - Mariarosaria Valente
- Clinical Neurology Unit, Santa Maria della Misericordia University Hospital, Piazzale Santa Maria della Misericordia, 15, 33010, Udine, Italy
- Neurology Unit, Department of Medicine (DAME), University of Udine Medical School, Udine, Italy
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16
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Majidi S, Luby M, Lynch JK, Hsia AW, Benson RT, Kalaria CP, Nadareishvili Z, Latour LL, Leigh R. MRI-based thrombolytic therapy in patients with acute ischemic stroke presenting with a low NIHSS. Neurology 2019; 93:e1507-e1513. [PMID: 31519779 DOI: 10.1212/wnl.0000000000008312] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 05/16/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Treatment of patients with stroke presenting with minor deficits remains controversial, and the recent Potential of rtPA for Ischemic Strokes with Mild Symptoms (PRISMS) trial, which randomized patients to thrombolysis vs aspirin, did not show benefit. We studied the safety and efficacy of thrombolysis in a population of patients with acute stroke presenting with low NIH Stroke Scale (NIHSS) scores screened using MRI. METHODS The NIH Natural History of Stroke database was reviewed from January 2006 to December 2016 to identify all patients with an initial NIHSS score ≤5 who received thrombolysis within 4.5 hours of symptom onset after being screened with MRI. The 24-hour postthrombolysis MRIs were reviewed for hemorrhagic transformation. Primary outcomes were symptomatic intracranial hemorrhage (sICH) and favorable 90-day outcome modified Rankin Scale score 0-1. Subgroup analysis was performed on patients who would have been eligible for the PRISMS trial, which enrolled patients with a nondisabling neurologic deficit. RESULTS A total of 121 patients were included in the study with a median age of 65 and an NIHSS score of 3; 63% were women. The rate of any hemorrhagic transformation was 13%, with 11% of them being limited to petechial hemorrhage. The rate of sICH was <1%. Sixty-six patients had 90-day outcome data; of those, 74% had a favorable outcome. For the subgroup of 81 PRISMS-eligible patients, none experienced sICH. Fifty of these patients had 90-day outcome data; of these, 84% had a favorable outcome. CONCLUSIONS Thrombolytic therapy was safe in our patients with stroke with minor deficits who were initially evaluated by MRI. Future studies of this population may benefit from MRI selection. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with acute ischemic stroke and NIHSS ≤5 screened with MRI, IV tissue plasminogen activator is safe.
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Affiliation(s)
- Shahram Majidi
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Marie Luby
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - John K Lynch
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Amie W Hsia
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Richard T Benson
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Chandni P Kalaria
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Zurab Nadareishvili
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Lawrence L Latour
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD
| | - Richard Leigh
- From the National Institute of Neurological Disorders and Stroke (S.M., M.L., J.K.L., A.W.H., R.T.B., C.P.K., Z.N., L.L.L., R.L.), NIH, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.P.K.), Washington, DC; and Johns Hopkins Community Physicians (Z.N.), Suburban Hospital, Bethesda, MD.
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17
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Garg R, Rech MA, Schneck M. Stroke Mimics: An Important Source of Bias in Acute Ischemic Stroke Research. J Stroke Cerebrovasc Dis 2019; 28:2475-2480. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/05/2019] [Accepted: 06/15/2019] [Indexed: 01/22/2023] Open
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18
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Itabashi R, Shigehatake Y, Yazawa Y, Endo K, Saito T, Fukuma K, Furui E, Mori E. Phased changes in strategies can reduce delay of intravenous thrombolysis administration to 15 min. J Neurol Sci 2019; 403:59-64. [PMID: 31226551 DOI: 10.1016/j.jns.2019.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 06/10/2019] [Accepted: 06/12/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The present study aimed to determine whether phased changes in strategies including the Helsinki model affect the delay of intravenous thrombolysis (IVT) using tissue plasminogen activator (tPA) to treat acute ischemic stroke. METHOD We retrospectively studied 516 consecutive patients treated with IVT in our department between October 2005 and December 2018. We implemented a system of hospital pre-notification in 2005, when IVT was initially implemented at our center. We then improved the IVT strategy by simplifying brain imaging (July 2011), premixing tPA (April 2014), locating a blood cell counter in the emergency room (June 2015), manually administering a tPA bolus before preparing a continuous infusion (January 2016), awarding a prize to members of the acute stroke team (November 2016), and completing registration before arrival and sending patients directly to computed tomography (February 2017). We analyzed the effects of these strategic changes on annual median door-to-needle times (DTN). RESULTS The DTN was annually reduced, from a median of 90 [interquartile range, 55-98] minutes in 2006 to 15 [12-24.25] minutes in 2017. By 2017, 94% of patients were treated within 60 min of arrival. Multivariate logistic regression analysis revealed that initial NIHSS score ≤ 4 (OR 2.67, 95% CI 1.3-5.7) and anticoagulation before onset (OR 6.00, 95% CI 2.47-14.58) were independently associated with 20 min or more of DTN in 186 patients treated from 2016 to 2018. CONCLUSIONS Phased strategic change to reduce the delay in delivering IVT reduced median DTN to 15 min at a single Japanese stroke center.
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Affiliation(s)
- Ryo Itabashi
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan; Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Japan.
| | | | - Yukako Yazawa
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Kaoru Endo
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Takuya Saito
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Kazuki Fukuma
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Eisuke Furui
- Departments of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Etsuro Mori
- Department of Behavioral Neurology and Neuropsychiatry, Osaka University United Graduate School of Child Development, Suita, Japan
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19
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Abstract
PURPOSE OF REVIEW This review details the frequency of and ways in which migraine can be both an ischemic stroke/transient ischemic attack mimic (false positive) and chameleon (false negative). We additionally seek to clarify the complex relationships between migraine and cerebrovascular diseases with regard to diagnostic error. RECENT FINDINGS Nearly 2% of all patients evaluated emergently for possible stroke have an ultimate diagnosis of migraine; approximately 18% of all stroke mimic patients treated with intravenous thrombolysis have a final diagnosis of migraine. Though the treatment of a patient with migraine with thrombolytics confers a low risk of complication, symptomatic intracerebral hemorrhage may occur. Three clinical prediction scores with high sensitivity and specificity exist that can aid in the diagnosis of acute cerebral ischemia. Differentiating between migraine aura and transient ischemic attacks remains challenging. On the other hand, migraine is a common incorrect diagnosis initially given to patients with stroke. Among patients discharged from an emergency visit to home with a diagnosis of a non-specific headache disorder, 0.5% were misdiagnosed. Further development of tools to quantify and understand sources of stroke misdiagnosis among patients who present with headache is warranted. Both failure to identify cerebral ischemia among patients with headache and overdiagnosis of ischemia can lead to patient harms. While some tools exist to help with acute diagnostic decision-making, additional strategies to improve diagnostic safety among patients with migraine and/or cerebral ischemia are needed.
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Affiliation(s)
- Oleg Otlivanchik
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, Bronx, NY, 10467, USA
| | - Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, Bronx, NY, 10467, USA.
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20
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Thrombolysis for atlantoaxial dislocation mimicking acute ischemic stroke. Am J Emerg Med 2019; 37:1216.e3-1216.e5. [PMID: 30940410 DOI: 10.1016/j.ajem.2019.03.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/27/2019] [Indexed: 01/30/2023] Open
Abstract
The frequency of stroke mimics among stroke patients has been reported to be up to 30%, and that in patients who receive thrombolytic therapy ranges between 1% and 16%. Atlantoaxial dislocation with myelopathy mimicking stroke is extremely rare. An 83-year-old man with a history of old cerebellar infarction presented to the emergency department with acute left hemiplegia after a chiropractic manipulation of the neck and back several hours before symptom onset. Mild hypoesthesia was observed on his left limbs. No speech disturbance, facial palsy, or neck or shoulder pain was observed. Intravenous thrombolytic treatment was given 238 min after symptom onset. Brown-Sequard syndrome subsequently developed 6 h after thrombolysis with a hypoesthetic sensory level below the right C5 dermatome. An emergent brain magnetic resonance angiography did not reveal an acute cerebral infarct but rather an atlantoaxial dislocation causing upper cervical spinal cord compression. Clinical symptoms did not deteriorate after thrombolysis. He received successful decompressive surgery 1 week later, and his muscle power gradually improved, with partial dependency when performing daily living activities 2 months later. A literature review revealed that only 15 patients (including the patient mentioned here) with spinal disorder mimicking acute stroke who received thrombolytic therapy have been reported. Atlantoaxial dislocation may present as acute hemiplegia mimicking acute stroke, followed by Brown-Sequard syndrome. Inadvertent thrombolytic therapy is likely not harmful for patients with atlantoaxial dislocation-induced cervical myelopathy. The neurological deficits of patients should be carefully and continuously evaluated to differentiate between stroke and myelopathy.
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21
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Abstract
Acute ischemic stroke is a major cause of mortality and morbidity in the United States and worldwide. Despite the development of specialized stroke centers, mortality and morbidity as a result of acute ischemic strokes can and do happen anywhere. These strokes are emergency situations requiring immediate intervention. This article covers the fundamentals of care involved in treating patients with acute ischemic stroke, including essentials for the initial evaluation, basic neuroimaging, reperfusion therapies, critical care management, and palliative care, as well as current controversies. National guidelines and current research are presented, along with recommendations for implementation.
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Affiliation(s)
- Bryan Boling
- Bryan Boling is Advanced Practice Provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky, 800 Rose St, Suite N204, Lexington, KY 40536 . Katie Keinath is Advanced Practice Provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky, Lexington, Kentucky
| | - Katie Keinath
- Bryan Boling is Advanced Practice Provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky, 800 Rose St, Suite N204, Lexington, KY 40536 . Katie Keinath is Advanced Practice Provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky, Lexington, Kentucky
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Zhang NN, Zhao KT, Zhao ZA, Chen WL, Xu HB, Chen HS. A novel rat model of cerebral artery occlusion complicated with prior venous stagnation. J Neurosci Methods 2019; 318:100-103. [PMID: 30703390 DOI: 10.1016/j.jneumeth.2019.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/25/2019] [Accepted: 01/26/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND To establish a novel rat model of middle cerebral artery occlusion (MCAO) complicated with prior venous stagnation, and to investigate the role of cerebral venous drainage in neural injury after acute cerebral infarction. NEW METHOD Eighteen SD rats were randomly divided into two groups: control group and jugular vein ligation group. The left jugular vein ligation was performed to produce the jugular venous stagnation. In the control group, the jugular vein was exposed but not ligated. Cerebral blood flow (CBF) was measured through laser speckle imaging before and after the surgery. At 1 week after the surgery, CBF was again measured and then a left MCAO was performed in both groups. At 24 h after MCAO, neurological deficit scoring was performed and the infarct volume was measured by 2,3,5-triphenyltetrazolium chloride staining. RESULTS Compared with the control group, a significant decrease in the CBF level was observed immediately after the ligation. A moderate recovery in CBF level was observed at 1 week after the ligation. The neurological deficit scores were significantly higher in the ligation group than in the control group at 24 h after the MCAO. Additionally, the volume of cerebral infarction increased significantly in the ligation group compared with that in the control group at the 24 h after MCAO. COMPARISON WITH EXISTING METHOD(S) AND CONCLUSIONS The novel rat model of cerebral artery occlusion complicated with long-term unilateral venous stagnation indicates cerebral venous drainage impairment may aggravate behavioral impairment and increase infarct volume after cerebral infarction.
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Affiliation(s)
- Nan-Nan Zhang
- Department of Neurology, General Hospital of Shenyang Military Region, Shenyang, 110840, PR China
| | - Kai-Tao Zhao
- Department of Neurology, General Hospital of Shenyang Military Region, Shenyang, 110840, PR China
| | - Zi-Ai Zhao
- Department of Neurology, General Hospital of Shenyang Military Region, Shenyang, 110840, PR China
| | - Wan-Li Chen
- Department of Neurology, General Hospital of Shenyang Military Region, Shenyang, 110840, PR China
| | - Hai-Bin Xu
- Department of Neurology, General Hospital of Shenyang Military Region, Shenyang, 110840, PR China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Shenyang Military Region, Shenyang, 110840, PR China.
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Abstract
BACKGROUND AND PURPOSE Patients who present emergently with acute neurological signs and symptoms represent unique diagnostic challenges for clinicians. We sought to characterize the reliability of physician diagnosis in differentiating aborted or imaging-negative acute ischemic stroke from stroke mimic. METHODS We constructed 10 case-vignettes of patients treated with thrombolysis with subsequent clinical improvement who lacked radiographic evidence of infarction. Using an online survey, we asked physicians to select a most likely final diagnosis after reading each case-vignette. Inter-rater agreement was evaluated using percent agreement and κ statistic for multiple raters with 95% confidence intervals reported. RESULTS Sixty-five physicians participated in the survey. Most participants were in practice for ≥5 years and over half were vascular neurologists. Physicians agreed on the most likely final diagnosis 71% of the time, κ of 0.21 (95% confidence interval, 0.06-0.54). Percent agreement was similar across participant practice locations, years of experience, subspecialty training, and personal experience with thrombolysis. CONCLUSIONS We found modest agreement among surveyed physicians in distinguishing ischemic stroke syndromes from stroke mimics in patients without radiographic evidence of infarction and clinical improvement after thrombolysis. Methods to improve diagnostic consensus after thrombolysis are needed to assure acute ischemic stroke patients and stroke mimics are treated safely and accurately.
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Terrin A, Toldo G, Ermani M, Mainardi F, Maggioni F. When migraine mimics stroke: A systematic review. Cephalalgia 2018; 38:2068-2078. [PMID: 29661036 DOI: 10.1177/0333102418767999] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Alberto Terrin
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | - Giulia Toldo
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | - Mario Ermani
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | | | - Ferdinando Maggioni
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
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Hsia AW, Burton TM. Author response: Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes. Neurology 2018; 90:199. [DOI: 10.1212/wnl.0000000000004850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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27
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Uchino K. Reader response: Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes. Neurology 2018; 90:199. [DOI: 10.1212/wnl.0000000000004872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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