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

Abstract

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.

Mimics and chameleons in stroke

“…6 In a 2016 US single hospital retrospective chart review, 20% of strokes were initially 'missed' although these data have limited generalisability to an entire healthcare system such as the NHS in the UK. 7 If the diagnosis of acute stroke continues to go unrecognised in patients who are initially admitted to general admissions units, the opportunity for secondary prevention can be lost. These patients can have delayed access to stroke unit care, which conveys an increased likelihood of being…”

“…8 It has been suggested that this group has higher rates of readmission at 60 days and disability and mortality at 12 months. 7,9 Stroke mimics Seizure, syncope, sepsis, migraine, space-occupying lesions, functional disorders and metabolic conditions are the seven most frequent differential diagnoses of suspected stroke. 10 Computerised tomography (CT) imaging can identify some space-occupying lesions and hypoglycaemia is detectable with bedside glucose monitoring.…”

“…9 In a recent analysis, 37% of posterior circulation strokes were initially missed compared with 16% of anterior circulation strokes, probably as patients presented with 'non-traditional' symptoms of confusion, altered gait and dizziness rather than conventional lateralising signs. 7,26 Acute vertigo Dizziness, unsteadiness and vertigo are common symptoms in the emergency department and on the medical take. The differential diagnosis includes posterior circulation stroke although most patients have more benign causes for their symptoms.…”

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

“…Misdiagnosis of acute stroke may result in worse patient functional outcomes due to failure to implement acute stroke interventions as well as standard processes of care [6]. Studies have reported that 2-26% of acute stroke presentations are misdiagnosed in the emergency department (ED) [5,[7][8][9][10]. Factors contributing to stroke misdiagnosis include non-specific or atypical symptoms [5,10], such as those associated with posterior circulation stroke (PCS) [8,10,11], decreased level of consciousness [9], younger patient age [8,9,12], lower cerebrovascular disease profile [8], and transient ischemic attack (TIA) [5].…”

Cerebellar Infarction and Factors Associated with Delayed Presentation and Misdiagnosis

“…Posterior circulation strokes are misdiagnosed 3 times more frequently than anterior circulation strokes [8] . Younger patient age [4,9] , nausea and or vomiting [8] , dizziness [8] , vertebral artery dissection [4] and prior history of stroke [8] are all associated with misdiagnosis of posterior circulation strokes. CBI most frequently involves the posterior inferior cerebellar arterial (PICA) territory but reported outcomes according to vascular territory involvement are inconsistent [4,6,10] .…”