Potentially Missed Diagnosis of Ischemic Stroke in the Emergency Department in the Greater Cincinnati/Northern Kentucky Stroke Study

Madsen, Tracy E.; Khoury, Jane; Cadena, Rhonda; Adeoye, Opeolu; Alwell, Kathleen; Moomaw, Charles J.; McDonough, Erin; Flaherty, Matthew L.; Ferioli, Simona; Woo, Daniel; Khatri, Pooja; Broderick, Joseph P.; Kissela, Brett M; Kleindorfer, Dawn

doi:10.1111/acem.13029

Cited by 56 publications

(55 citation statements)

References 19 publications

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“…Numerous studies have found that women are more likely than men to report nonfocal symptoms when presenting with acute ischemic stroke 2,3,25 and that the presence of nonfocal symptoms is associated with misdiagnosis. 5, 13,26 We did not find any substantial sex differences in presenting symptoms, but we observed that women and men who reported focal stroke symptoms, with or without accompanying nonfocal symptoms, were at increased risk of having evidence of acute infarct on MRI and were more likely to receive a diagnosis of TIA or stroke. Contrary to the classic teaching that "nonspecific" or "atypical" symptoms are usually associated with stroke mimics, our findings suggested that nonfocal symptoms were common in minor ischemic cerebrovascular events and that these symptoms should not discourage clinicians from pursuing investigations for cerebral ischemia.…”

Section: Discussionmentioning

confidence: 59%

Sex Differences in Presentation and Outcome After an Acute Transient or Minor Neurologic Event

Penn

Lesperance

et al. 2019

JAMA Neurol

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; for the SpecTRA Study Group IMPORTANCE Sex differences have been described in the presentation, care, and outcomes among people with acute ischemic strokes, but these differences are less understood for minor ischemic cerebrovascular events. The present study hypothesized that, compared with men, women are more likely to report nonfocal symptoms and to receive a stroke mimic diagnosis. OBJECTIVE To evaluate sex differences in the symptoms, diagnoses, and outcomes of patients with acute transient or minor neurologic events. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study of patients with minor ischemic cerebrovascular events or stroke mimics enrolled at multicenter academic emergency departments in Canada between December 2013 and March 2017 and followed up for 90 days is a substudy of SpecTRA (Spectrometry for Transient Ischemic Attack Rapid Assessment). In total, 1729 consecutive consenting patients with acute transient or minor neurologic symptoms were referred for neurologic evaluation; 66 patients were excluded for protocol violation (n = 46) or diagnosis of transient global amnesia (n = 20). EXPOSURES The main exposure was female or male sex. MAIN OUTCOMES AND MEASURES The main outcome was the clinical diagnosis (cerebral ischemia vs stroke mimic). Secondary outcomes were 90-day stroke recurrence and 90-day composite outcome of stroke, myocardial infarction, or death. The association between presenting symptoms (focal vs nonfocal) and clinical diagnosis was also assessed. Research hypotheses were formulated after data collection. RESULTS Of 1648 patients included, 770 (46.7%) were women, the median (interquartile range) age was 70 (59-80) years, 1509 patients (91.6%) underwent brain magnetic resonance imaging, and 1582 patients (96.0%) completed the 90-day follow-up. Women (522 of 770 [67.8%]) were less likely than men (674 of 878 [76.8%]) to receive a diagnosis of cerebral ischemia (adjusted risk ratio [aRR], 0.88; 95% CI, 0.82-0.95), but the 90-day stroke recurrence outcome (aRR, 0.90; 95% CI, 0.48-1.66) and 90-day composite outcome (aRR, 0.86; 95% CI, 0.54-1.32) were similar for men and women. No significant sex differences were found for presenting symptoms. Compared with patients with no focal neurologic symptoms, those with focal and nonfocal symptoms were more likely to receive a diagnosis of cerebral ischemia (aRR, 1.28; 95% CI, 1.15-1.39), but the risk was highest among patients with focal symptoms only (aRR, 1.45; 95% CI, 1.34-1.53). Sex did not modify these associations. CONCLUSIONS AND RELEVANCE The results of the present study suggest that, despite similar presenting symptoms among men and women, women may be more likely to receive a diagnosis of stroke mimic, but they may not have a lower risk than men of subsequent vascular events, indicating potentially missed opportunities for prevention of vascular events among women.

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Section: Discussionmentioning

confidence: 59%

Sex Differences in Presentation and Outcome After an Acute Transient or Minor Neurologic Event

Penn

Lesperance

et al. 2019

JAMA Neurol

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“…It is unclear whether an earlier stroke diagnosis in our "missed" cohort would have improved outcome. In the Greater Cincinnati/Northern Kentucky Stroke Study, only 1.1% of patients with a stroke misdiagnosis were eligible for IVT [9]. Not surprisingly, none of our misdiagnosed patients received acute stroke intervention.…”

Section: Discussionmentioning

confidence: 76%

“…Due to the study design, we were also unable to determine whether patient age [9,12] and language discordance were relevant factors.…”

Section: Discussionmentioning

confidence: 99%

“…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].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2018

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Background: Failure to recognise acute stroke may result in worse outcomes due to missed opportunity for acute stroke therapies. Our study examines factors associated with stroke misdiagnosis in patients admitted to a large comprehensive stroke centre. Methods: Retrospective review comparing 156 consecutive stroke patients misdiagnosed in emergency department (ED) with 156 randomly selected stroke controls matched for age, gender, language spoken and stroke subtype for the period 2014–2016. Results: There were 141 ischemic and 15 hemorrhagic misdiagnosed strokes (median age: 77 years, male:female = 1.3: 1). Symptom resolution, altered mental status, nausea/vomiting, dizziness and vertigo favored misdiagnosis (p < 0.05). Hemiparesis and dysarthria favored an accurate diagnosis (p < 0.05). Misdiagnosed patients were more commonly triaged into a lower ED category (62 vs. 42%, p = 0.001), clinically assessed as Face, Arm, Speech and Time (FAST) – negative (78 vs. 22%, p < 0.001) and underwent delayed CT imaging (median 4.1 vs. 1.5 h, p < 0.001). Misdiagnosed patients were more likely to have posterior circulation stroke (PCS; 39 vs. 22%, p = 0.01) and be admitted under non-neurological services (35 vs. 11%, p < 0.001) with worse discharge outcomes including increased mortality. Conclusions: Patients with stroke misdiagnosis were commonly FAST-negative with nonspecific symptoms including altered mental status, dizziness and nausea/vomiting often associated with PCS. Improved diagnostic accuracy may increase access to acute therapies.

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“…After the turn of the millennium, the increased availability of MRI and perfusion CT imaging means more cases of minor or transient symptoms can now be recognized to be of ischemic origin. This might be of particular relevance in younger patients, in whom IS is more easily missed initially [ 22 ]. Also, the current, tissue-based definition of a transient ischemic attack (TIA), may have resulted in more cases of transient symptoms to be classified as infarcts as compared to the previous, time-dependent definition [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

Stroke hospitalization trends of the working-aged in Finland

et al. 2018

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BackgroundThe age-standardized incidence of stroke has decreased globally but, for reasons unknown, conflicting results have been observed regarding trend in incidence of major stroke subtypes in young adults. We studied these trends among people of working age in a population-based setting in Finland, where cardiovascular risk factor profiles have developed favorably.MethodsAll hospitalizations for stroke in 2004–2005 and 2013–2014 for persons 18–64 years of age were identified from a national register. The search included all hospitals that provide acute stroke care on mainland Finland.ResultsHospitalizations for both intracerebral hemorrhage (ICH; -15.2%; p = 0.0008) and subarachnoid hemorrhage (SAH; -26.5%; p<0.0001) decreased overall and for both sexes separately. Concerning IS, hospitalizations decreased only for men (-6.3%; p = 0.0190) but not for women or overall. However, there was an increase in IS hospitalizations in men 35–44 years of age (+37.5%; p = 0.0019). The length of stay (LOS) of IS patients declined in nearly all subgroups (overall -20.8%, p<0.0001) whereas no change in LOS was observed for patients with ICH or SAH. In-hospital mortality decreased in patients with IS (-42.8%; p = 0.0092) but remained unchanged in patients with ICH or SAH.ConclusionsStroke hospitalizations of young people declined in Finland, except for men 35–44 years of age for whom IS hospitalizations increased. Declining LOS and in-hospital mortality of IS patients suggests admission of less severe cases, improved care or both.

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Potentially Missed Diagnosis of Ischemic Stroke in the Emergency Department in the Greater Cincinnati/Northern Kentucky Stroke Study

Cited by 56 publications

References 19 publications

Sex Differences in Presentation and Outcome After an Acute Transient or Minor Neurologic Event

Sex Differences in Presentation and Outcome After an Acute Transient or Minor Neurologic Event

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

Stroke hospitalization trends of the working-aged in Finland

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