Misdiagnosis of Transient Ischemic Attacks in the Emergency Room

Abstract

Background: To determine a pattern of symptoms and/or risk factors that distinguishes transient ischemic attack (TIA) from nonischemic causes of transient neurologic attacks (NI-TNA). Methods: We reviewed demographic, clinical, and hospital data on 100 consecutive patients with transient focal neurologic episode(s) lasting less than 24 h and in whom the initial diagnosis was TIA. After inpatient evaluation and review, final diagnoses were made by two stroke neurologists. Using stepwise multivariable logistic regression, we estimated odds ratios (OR) for independent predictors of NI-TNA. p < 0.05 was considered significant. Results: Of the 100 patients, 40 were confirmed to have TIA and 60 NI-TNA. Compared to TIA patients, those with NI-TNA were less likely to be male and white but more likely to have a history of prior unexplained TNA, gradual symptom onset, associated nonspecific symptoms, longer symptom duration, and delayed presentation. Other variables were similar between the two groups. In a multivariable logistic regression model, gradual symptom onset (adjusted OR 6.7, p = 0.002), prior history of unexplained transient neurologic attack (adjusted OR 10.6, p = 0.031), and presence of nonspecific symptoms (adjusted OR 4.2, p = 0.008) were independent predictors of the final diagnosis of NI-TNA. Conclusions: Distinguishing TIA from nonischemic causes is difficult in the emergency room, with 60% of suspected TIA patients having nonischemic causes on inpatient evaluation. We found 3 clinical features that may be useful in the emergency room triage of transient neurologic attacks. Further study is needed to develop tools that can accurately diagnose TIA.

Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic

“…[23][24][25] In our study, the discharge diagnosis of TIA agreed with the diagnosis after being seen in the neurovascular clinic in 86.4% of patients. Including or excluding these patients did not change our results.…”

Isolated transient aphasia at emergency presentation is associated with a high rate of cardioembolic embolism

“…Some investigators have reported a false diagnosis rate of up to 60% in one U.S. study of inpatients initially assessed by an emergency physician, including those with gradual onset and nonspecific neurological symptoms. 26 These results are not unexpected given the transient nature of the symptoms and the fact that many patients present at a time when their symptoms have already started to resolve. We believe that, given the specific nature of isolated aphasia, the subsequent stroke risk, and the explicit, prospective identification of neurological signs and symptoms as well as other elements of our study, the large majority of patients in our cohort had a TIA.…”

Diagnosis and Management of Transient Ischemic Attack

“…Studies have shown up to an 80% reduction in the risk of stroke after TIA with the early implementation of secondary stroke prevention strategies, 11,12 including revascularization of patients with symptomatic carotid artery stenosis, anticoagulation of patients with atrial fibrillation, treatment with antiplatelet agent(s), treatment with statins for most patients, management of hypertension, and lifestyle…”