Misdiagnosis of stroke

Soluble Epoxide Hydrolase as a Therapeutic Target for Neuropsychiatric Disorders

It has been found that soluble epoxide hydrolase (sEH; encoded by the EPHX2 gene) in the metabolism of polyunsaturated fatty acids (PUFAs) plays a key role in inflammation, which, in turn, plays a part in the pathogenesis of neuropsychiatric disorders. Meanwhile, epoxy fatty acids such as epoxyeicosatrienoic acids (EETs), epoxyeicosatetraenoic acids (EEQs), and epoxyeicosapentaenoic acids (EDPs) have been found to exert neuroprotective effects in animal models of neuropsychiatric disorders through potent anti-inflammatory actions. Soluble expoxide hydrolase, an enzyme present in all living organisms, metabolizes epoxy fatty acids into the corresponding dihydroxy fatty acids, which are less active than the precursors. In this regard, preclinical findings using sEH inhibitors or Ephx2 knock-out (KO) mice have indicated that the inhibition or deficiency of sEH can have beneficial effects in several models of neuropsychiatric disorders. Thus, this review discusses the current findings of the role of sEH in neuropsychiatric disorders, including depression, autism spectrum disorder (ASD), schizophrenia, Parkinson’s disease (PD), and stroke, as well as the potential mechanisms underlying the therapeutic effects of sEH inhibitors.

Role of epoxy-fatty acids and epoxide hydrolases in the pathology of neuro-inflammation

Neuroinflammation is a physiologic response aimed at protecting the central nervous system during injury. However, unresolved and chronic neuroinflammation can lead to long term damage and eventually neurologic disease including Parkinson's disease, Alzheimer's disease and dementia. Recently, enhancing the concentration of epoxyeicosatrienoic acids (EETs) through blocking their hydrolytic degradation by soluble epoxide hydrolase (sEH) has been applied towards reducing the long-term damage associated with central neurologic insults. Evidence suggests this protective effect is mediated, at least in part, through polarization of microglia to an anti-inflammatory phenotype that blocks the inflammatory actions of prostaglandins and promotes wound repair. This mini-review overviews the epidemiologic basis for using sEH inhibition towards neuroinflammatory disease and pharmacologic studies testing sEH inhibition in several neurologic diseases. Additionally, the combination of sEH inhibition with other eicosanoid signaling pathways is considered as an enhanced approach for developing potent neuroprotectants.

Simultaneous event of brachial artery occlusion and acute embolic stroke

Although the rapid and accurate diagnosis of both acute ischemic stroke and extremity ischemia is essential to the timely and appropriate treatment, it is not always easy to differentiate between true stroke and stroke mimics. Although in general, limb ischemia due to extremity embolism is not included in stroke mimics or misdiagnosis, limb arterial embolism should be considered in thedifferential diagnosis of acute monoparesis because the diagnosis maybe missed if the other typical manifestations of this presentation(pain, pallor, pulselessness, sensory loss, and coolness of the arm) are overlooked. Therefore, it is important to ensure that important signsare not missed whether the evaluation of the patient is done at thebedside. We report a case of a male patient presented to an emergency department with acute right upper extremity pain with headache, gait disturbance, and confused mentality. He was diagnosed by simultaneou sbrachial artery occlusion and acute stroke, which resulted in emergency surgical embolectomy and anticoagulation therapy.

Stroke mimics under the drip-and-ship paradigm

BACKGROUND

Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. We hypothesized that a higher rate of stroke mimics (SM) among AIS treated in nonspecialized stroke centers that are transferred to comprehensive centers is responsible for such outcomes.

METHODS

Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over 1 academic year (July 1, 2011 to June 30, 2012). Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge disposition was collected. We identified those patients who were treated at a facility and then transferred to the tertiary center (ie, drip-and-ship paradigm). In addition to comparative and adjusted analysis to identify predictors for SM, a stratified analysis by the drip-and-ship status was performed.

RESULTS

One hundred twenty patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = .0003) and more likely to harbor psychiatric diagnoses (45% versus 9%; P ≤ .0001). Eighteen of 20 SM patients (90%) had the drip-and-ship treatment paradigm compared with 65% of those with AIS (P = .02). None of the SM had hemorrhagic complications, and all were discharged to home. Predictors of SM on adjusted analysis included the drip-and-ship paradigm (odds ratio [OR] 12.8, 95% confidence interval [CI] 1.78, 92.1) and history of any psychiatric illness (OR 12.08; 95% CI 3.14, 46.4). Eighteen of 83 drip-and-ship patients (21.7%) were diagnosed with SM compared with 2 of 37 patients (5.4%) presented directly to the hub hospital (P = .02).

CONCLUSION

The drip-and-ship paradigm and any psychiatric history predict the diagnosis of SM. None of the SM had thrombolysis-related complications, and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment for AIS.

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.

Missed opportunities for recognition of ischemic stroke in the emergency department

INTRODUCTION

Evidence suggests that a significant number of patients discharged from the hospital with a diagnosis of ischemic stroke are not identified as having a stroke on admission. Those presenting with "nontraditional" stroke symptoms may be less likely to be diagnosed correctly. We aimed to establish whether there was an association between symptom presentation and diagnostic accuracy and to identify the type and frequency of nontraditional symptoms that resulted in a missed diagnosis in the emergency department.

METHODS

We reviewed the medical records of 189 patients discharged with a diagnosis of ischemic stroke from Yale-New Haven Hospital. We performed χ(2) analysis to determine whether an association existed between symptom presentation and diagnostic accuracy. Descriptive statistics allowed us to identify symptom type and frequency in patients with a missed diagnosis.

RESULTS

A diagnosis of suspected stroke was missed in 15.3% of patients who presented to the emergency department. We found a strong association (P < 0.0001) between symptom presentation and diagnostic accuracy. Of the patients presenting with any "traditional" symptom, 4% were missed. Of those presenting with only nontraditional symptoms, 64% were missed (odds ratio, 43.4; 95% confidence interval, 15.0-125.4). Nontraditional symptoms included generalized weakness, altered mental status, altered gait, and dizziness.

DISCUSSION

In order to facilitate appropriate management of patients with ischemic stroke, emergency nurses must be aware that symptom presentation is highly variable. Patients presenting with nontraditional symptoms may benefit from an immediate and comprehensive neurological evaluation.

Atypical presentations of acute cerebrovascular syndromes

Correct diagnosis of acute stroke is of paramount importance to clinicians to enable selection of correct treatments and to ensure prevention of acute complications, including recurrent stroke. Timely diagnosis can be difficult in some cases because patients with acute stroke can present with atypical or uncommon symptoms that suggest another cause altogether. Publications on these patients suggest that the following strategies could help to reduce misdiagnosis. First, clinicians should suspect stroke in any patient with abrupt onset of neurological symptoms. Second, clinicians should be aware that some patients will initially present with various uncommon and atypical stroke symptoms. Third, a complete and systematic neurological examination should be routinely done in patients presenting with acute neurological symptoms because this might shed light on the true nature of the problem. Finally, clinicians should be aware that even with the most sophisticated neuroimaging tests, stroke might be missed in the early hours after the event.

The complexity of neurobiological processes in acute ischemic stroke

There is an urgent need for improved diagnostics and therapeutics for acute ischemic stroke. This is the focus of numerous research projects involving in vitro studies, animal models and clinical trials, all of which are based on current knowledge of disease mechanisms underlying acute focal cerebral ischemia. Insight in the chain of events occurring during acute ischemic injury is essential for understanding current and future diagnostic and therapeutic approaches. In this review, we summarize the actual knowledge on the pathophysiology of acute ischemic stroke. We focus on the ischemic cascade, which is a complex series of neurochemical processes that are unleashed by transient or permanent focal cerebral ischemia and involves cellular bioenergetic failure, excitotoxicity, oxidative stress, blood-brain barrier dysfunction, microvascular injury, hemostatic activation, post-ischemic inflammation and finally cell death of neurons, glial and endothelial cells.