Emergency department evaluation of ischemic stroke and TIA

Brown, Devin L.; Lisabeth, Lynda D.; Garcia, Nelda; Smith, M. A.; Morgenstern, Lewis B.

doi:10.1212/01.wnl.0000147292.64051.9b

Cited by 64 publications

(45 citation statements)

References 19 publications

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“…Previous studies support neurologist involvement in the ED as a way to improve acute stroke diagnosis, although this may not be feasible at all institutions. 15,16 In order for a neurologist to be consulted though, the ED has to first consider stroke. An atypical stroke symptom such as nausea/vomiting may not trigger a neurology consult or even an initial neurological examination.…”

Section: March 2016mentioning

confidence: 99%

Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services

Arch

Weisman

Coca

et al. 2016

Stroke

154

106

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A retrospective chart review was performed on all patients with a discharge diagnosis of ischemic stroke during a 1-year period from Background and Purpose-The failure to recognize an ischemic stroke in the emergency department is a missed opportunity for acute interventions and for prompt treatment with secondary prevention therapy. Our study examined the diagnosis of acute ischemic stroke in the emergency department of an academic teaching hospital and a large community hospital. Methods-A retrospective chart review was performed from February 2013 to February 2014. Results-A total of 465 patients with ischemic stroke were included in the analysis; 280 patients from the academic hospital and 185 patients from the community hospital. One hundred three strokes were initially misdiagnosed that is 22% of the included strokes at the combined centers. Fifty-five of these were missed at the academic hospital (20%) and 48 were at the community hospital (26%, P=0.11). Thirty-three percent of missed cases presented within a 3-hour time window for recombinant tissue-type plasminogen activator eligibility. An additional 11% presented between 3 and 6 hours of symptom onset for endovascular consideration. Symptoms independently associated with greater odds of a missed stroke diagnosis were nausea/vomiting (odds ratio, 4.02; 95% confidence interval, 1.60-10.1), dizziness (odds ratio, 1.99; 95% confidence interval, 1.03-3.84), and a positive stroke history (odds ratio, 2.40; 95% confidence interval, 1.30-4.42). Thirty-seven percent of posterior strokes were initially misdiagnosed compared with 16% of anterior strokes (P<0.001). Conclusions-Atypical symptoms associated with posterior circulation strokes lead to misdiagnoses. This was true at both an academic center and a large community hospital. Future studies need to focus on the evaluation of identification systems and tools in the emergency department to improve the accuracy of stroke diagnosis. (Stroke. 2016;47:668-673.

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Section: March 2016mentioning

confidence: 99%

Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services

Arch

Weisman

Coca

et al. 2016

Stroke

154

106

View full text Add to dashboard Cite

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“…Although some 16,17 but not all studies 18 have shown less access to specialist (neurologist) care for minority stroke patients in the emergency department or hospital setting, few studies have assessed racial/ethnic differences in more general access measures and in a population-based fashion. Among US veterans hospitalized with ischemic stroke, outpatient utilization of both general medicine and neurology in the VA health system was lower for whites compared with blacks, although non-VA Medicare health care utilization was not captured and may have been higher among the older whites.…”

Section: Discussionmentioning

confidence: 99%

Racial/ethnic disparities in access to physician care and medications among US stroke survivors

et al. 2011

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“…4 Several studies that have reported on the frequency of IV rt-PA use in both men and women have shown a trend toward women being less likely to receive treatment. These reports have included a wide range of study designs including prospective studies from academic medical centers, 5,6 or community-based hospitals, 7 retrospective studies from community-based hospitals, 8,9 stroke registries, 10 -12 and administrative databases. 13,14 Although previous reviews have suggested that that the use of IV rt-PA is lower in women, 15 as far as we are aware, no systematic review or meta-analysis has been conducted to determine whether there is a genderbased disparity in the use of IV rt-PA for acute ischemic stroke, and whether such a discrepancy is a consistent finding across studies.…”

mentioning

confidence: 99%

Sex Differences in the Use of Intravenous rt-PA Thrombolysis Treatment for Acute Ischemic Stroke

Reeves

Bhatt

Jajou

et al. 2009

Stroke

130

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Background and Purpose-Some studies report that women are less likely to receive IV rt-PA treatment for stroke than men. We undertook a meta-analysis to determine whether a sex disparity existed. Methods-We identified studies that reported sex-specific IV rt-PA treatment rates for acute stroke. Eligible studies included acute stroke admissions from single or multiple hospitals, registries, or administrative databases. Random effects odds ratios (OR) and 95% confidence intervals (CI) were generated to quantify sex differences (females versus males) among all ischemic stroke admissions and among the eligible subgroup who arrived within 3 hours without contraindications. Study design and geographic location were explored as sources of heterogeneity. Results-Eighteen studies were included. Study designs included single hospitals (nϭ5), multiple hospitals (nϭ6), registries (nϭ4), and administrative databases (nϭ3). The summary OR was 0.70 (95% CIϭ0.55 to 0.88) indicating that women had a 30% lower odds of receiving rt-PA treatment than men. However, substantial between-study variability existed. Among 13 hospital-based studies, the summary OR was 0.78 (95% CIϭ0.71 to 0.86) with no significant heterogeneity. Among the 3 administrative studies, the OR was 0.55 (95% CIϭ0.34 to 0.90) but with significant heterogeneity. Among 4 studies that included data on the eligible subgroup, women had a nonsignificant lower odds of treatment (ORϭ0.81, 95% CIϭ0.58 to 1.13). Conclusions-Despite the presence of significant between-study variation, women with acute stroke were consistently less likely to receive thrombolysis treatment compared with men. Further studies to explore the origins of this sex disparity are warranted.

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Emergency department evaluation of ischemic stroke and TIA

Abstract: Neurologists are seldom involved with acute cerebrovascular care in the emergency department (ED), especially in patients with TIA. Greater neurologist involvement may improve acute stroke diagnosis and treatment efforts in the ED.

Cited by 64 publications

References 19 publications

Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services

Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services

Racial/ethnic disparities in access to physician care and medications among US stroke survivors

Sex Differences in the Use of Intravenous rt-PA Thrombolysis Treatment for Acute Ischemic Stroke

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