This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kothari, R. U. Articles by Hamilton, C. A. Search for Related Content PubMed PubMed Citation Articles by Kothari, R. U. Articles by Hamilton, C. A.

(Stroke. 1995;26:2238-2241.)
© 1995 American Heart Association, Inc.

Articles

Emergency Physicians

Accuracy in the Diagnosis of Stroke

Rashmi U. Kothari, MD; Thomas Brott, MD; Joseph P. Broderick, MD Cathy A. Hamilton, RN, MPH

From the Departments of Emergency Medicine (R.U.K., C.A.H.) and Neurology (T.B., J.P.B.), University of Cincinnati (Ohio).

Correspondence to Rashmi U. Kothari, MD, Department of Emergency Medicine, University of Cincinnati College of Medicine, PO Box 670769, Cincinnati, OH 45267-0769.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose The role of emergency physicians in trials of acute stroke therapy is expanding. We investigated the ability of emergency physicians to accurately identify patients with stroke.

Methods We reviewed all 446 patients who were evaluated in the emergency department and had an inpatient admitting or discharge diagnosis of ischemic or hemorrhagic stroke from May 1, 1992, to June 30, 1993. The final admitting diagnosis made by the emergency physician was compared with the final hospital discharge diagnosis, 95% of which were made by neurologists or neurosurgeons.

Results All 76 patients with a final discharge diagnosis of intracerebral or subarachnoid hemorrhage were correctly diagnosed by the emergency physicians (sensitivity, 100%; positive predictive value, 100%). Of the 351 patients with a final discharge diagnosis of ischemic stroke or transient ischemic attack, 346 were correctly identified by the emergency physicians (sensitivity, 98.6%; positive predictive value, 94.8%). Nineteen patients were diagnosed with stroke or transient ischemic attack by the emergency physician but had a final discharge diagnosis other than stroke. Discharge diagnoses included paresthesia or numbness of unknown causes (3), seizure (2), complicated migraine (2), peripheral neuropathy (2), cranial nerve neuropathy (2), psychogenic paralysis (1), and other (7).

Conclusions Emergency physicians at a large urban teaching hospital with a comprehensive stroke intervention program can accurately identify patients with stroke, particularly hemorrhagic stroke. If similar accuracy can be documented in other types of hospitals, emergency physicians may become key providers of urgent stroke intervention.

Key Words: cerebral infarction • computed tomography • diagnosis • emergency medical services • stroke assessment

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Emergency physicians are often the first physicians to evaluate and treat patients with an acute stroke.^{1 2} Proper treatment depends on differentiating stroke patients from patients who have other acute illnesses, as well as correctly identifying whether patients have a hemorrhagic or an ischemic stroke. If thrombolytic therapy is found to be effective in ischemic strokes, diagnostic accuracy will play an even more crucial role in treatment. We investigated the accuracy of emergency physicians in the diagnosis of stroke and stroke subtypes.

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The University of Cincinnati Medical Center is a 707-bed teaching institution with a residency training program in emergency medicine. The emergency department is an urban, level-1 trauma center with 65 000 visits per year. All emergency department patients are evaluated by residents who are supervised by residency-trained and board-certified emergency medicine faculty. The decision to admit and the admitting diagnosis are made by the emergency medicine resident and faculty. In questionable cases, telephone consultation by a board-certified neurologist is available. Emergency department consultation by a neurosurgery resident is obtained after the diagnosis of hemorrhagic stroke is made by the emergency physician.

A computerized retrospective search of all hospital admissions from the emergency department was performed from May 1, 1992, to June 30, 1993. Cases were identified if they had a primary admitting or final inpatient discharge diagnosis of ischemic or hemorrhagic stroke (International Classification of Diseases, 9th Revision codes 430, 431, and 433 to 437) and were admitted through the emergency department. To ensure that all potential patients were identified, we manually reviewed all emergency department visits for the study period for clinical findings suggestive of stroke or transient ischemic attack (TIA) or an admitting or discharge diagnosis of stroke or TIA.³ Patients evaluated in the emergency department but not admitted to the hospital were excluded from the study.

Telephone consultations by an attending neurologist were not consistently documented on emergency department records. To estimate the number of stroke-related neurology telephone consultations to the emergency department, a 1-month log was kept of all stroke-related consultations by the on-call attending neurologist and the Cincinnati/Northern Kentucky Stroke Team neurologists (T.B. and J.P.B.).

For patients admitted to the hospital, the admitting diagnosis made by the emergency physician was compared with the final hospital discharge diagnosis. If a patient had two emergency department admitting diagnoses (eg, rule out seizure versus TIA), concordance was assumed if the final hospital discharge diagnosis corresponded to one of the admitting diagnoses. Analysis was also completed assuming discordance between the emergency diagnosis and the discharge diagnosis on patients with two admitting diagnosis. Ninety-five percent of the final hospital discharge diagnoses of stroke or TIA were made by neurologists or neurosurgeons. In three cases, the discharge diagnosis did not specifically mention stroke or TIA but was suggestive of a stroke or TIA (eg, "unilateral arm weakness"). If the discharge summary stated that the findings were consistent with a cerebrovascular event, the case was reviewed by three study investigators. If unanimous agreement was reached that the case was likely a stroke or TIA, the case was placed into the stroke or TIA category.

All patients admitted as stroke or TIA from the emergency department had a noncontrast CT of the head before admission. These scans were interpreted by emergency physicians or radiologists from 8 AM to 5 PM weekdays and by emergency physicians alone at all other times. Those patients correctly diagnosed with stroke or TIA by emergency physicians were compared with those incorrectly diagnosed with stroke in terms of age, sex, race, and history of stroke or TIA. Age was analyzed with Student's t test. All other factors were analyzed with the ² test.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Of 77 024 emergency department visits during the 14-month study period, 463 patients (0.6%) had an emergency department diagnosis of stroke or TIA. Twenty-two patients were discharged from the emergency department, and 441 (4% of all admissions) were hospitalized. Twelve patients were admitted with two admitting diagnoses, one of which included ischemic stroke or TIA (eg, rule out stroke versus seizure). Of these 12 patients, 5 had a final diagnosis of stroke or TIA, and 7 had a nonstroke diagnosis. Of 12 057 patients admitted to the hospital from the emergency department during the study period, 427 had a final inpatient discharge diagnosis of stroke or TIA. Three patients had hospital discharge summaries that stated stroke or TIA but had final coded diagnoses other than stroke or TIA. After review by three study physicians, all three cases were included as strokes or TIAs.

The mean age for the 441 patients with an admitting diagnosis of stroke was 63 years. More than half of these patients were female (57%) and black (62%). Of these patients, 422 (96%) were discharged with a final diagnosis of stroke or TIA (Figure). The other 19 patients (4%) were given a diagnosis of stroke or TIA by the emergency physician but had a final hospital discharge diagnosis other than stroke or TIA (Table 1).

View larger version (28K): [in this window] [in a new window]   Figure 1. Circle graph shows final hospital discharge diagnoses of patients admitted through the emergency department with a diagnosis of stroke or transient ischemic attack (n=441).

View this table: [in this window] [in a new window]   Table 1. Discharge Diagnosis of Patients Misdiagnosed With Stroke by Emergency Physicians

All 76 patients with a final discharge diagnosis of intracerebral or subarachnoid hemorrhage were correctly diagnosed by the emergency physician before neurosurgery consultation (sensitivity, 100%; positive predictive value [PPV], 100%; Table 2). In addition, emergency physicians correctly diagnosed 346 of 351 patients with ischemic stroke or TIA (sensitivity, 98.6%; PPV, 94.8%; Table 2). If discordance was assumed on all 12 patients with two admitting diagnosis (eg, stroke versus seizure), the sensitivity is 97.2% and the PPV is 92.6%.

View this table: [in this window] [in a new window]   Table 2. Emergency Physician Diagnosis of Hemorrhagic Stroke vs Final Hospital Discharge Diagnosis

Of the 365 patients initially diagnosed with ischemic stroke or TIA by the emergency physician, 19 (5%) were discharged with a final diagnosis other than stroke or TIA (Table 3). It is not known how many of the 365 initial diagnoses of ischemic stroke or TIA were made in conjunction with a neurological telephone consultation. During a 1-month surveillance period, there was one neurology telephone consultation and eight stroke team consultations (two of which were in-person consultations) regarding a potential stroke patient. In only three of these cases did the neurologist give assistance in the diagnosis. Two of these three patients were eventually diagnosed with stroke. There were 32 patients admitted with a diagnosis of stroke or TIA during this 1-month surveillance period.

View this table: [in this window] [in a new window]   Table 3. Emergency Physician Diagnosis of Ischemic Stroke or TIA vs Final Hospital Discharge Diagnosis

Of the 19 patients discharged with a diagnosis other than stroke or TIA (Table 1), the most common final hospital discharge diagnoses included paresthesia or numbness of unknown causes (3), seizure (2), complicated migraine (2), peripheral neuropathy (2), cranial nerve neuropathy (2), and psychogenic paralysis (1). There was a strong trend for these patients to be younger than those correctly diagnosed with stroke or TIA by emergency physicians (mean age of 55 years versus 65 years; P=.06). There was no difference between these two groups in terms of race (P=.59), sex (P=.48), or history of stroke (P=.14).

Five patients (1%) of the 427 patients with a discharge diagnosis of stroke or TIA received diagnoses other than stroke by emergency physicians (Table 4).

View this table: [in this window] [in a new window]   Table 4. Stroke Patients Initially Misdiagnosed by Emergency Physicians

Patients discharged home from the emergency department with a diagnosis of stroke or TIA were excluded from the study and had no further follow-up. On review of the emergency department records by study investigators (C.A.H. and R.U.K.), there were no patients with clinical signs or symptoms suggestive of a stroke or TIA who were discharged home from the emergency department with a diagnosis other than stroke.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Clinicians have begun to view stroke as a medical emergency of a magnitude similar to that of trauma victims and patients with acute myocardial infarctions.^{4 5 6 7 8} The need for rapid identification and treatment of patients with acute stroke has been emphasized by recent therapeutic trials.^{9 10 11 12 13} Emergency physicians currently play a crucial link in the early evaluation and management of trauma and heart attack victims. Systems have been established that allow treatment within the "golden hour" for these patients. A similar strategy using emergency physicians may be effective in the management of acute stroke.

A major concern regarding the role of emergency physicians in the evaluation and treatment of stroke patients is diagnostic accuracy. We found that emergency physicians with neurological telephone consultation could identify 98% of ischemic strokes (sensitivity, 98.6%; specificity, 99.8%) and were correct 95 of 100 times when they identified a patient as having had a stroke or TIA (PPV, 94.8%). It may be argued that an error rate of 5% is unacceptable if one is giving potentially life-threatening drugs (eg, thrombolytics). This study did not address the accuracy of emergency physicians in identifying patients for therapeutic intervention but rather evaluated emergency physicians' accuracy in identifying the most likely diagnoses for these patients. The specificity and PPV may improve at the expense of sensitivity if emergency physicians were asked if they were confident enough in their diagnosis of stroke to treat the patient with a potentially life-threatening agent. In addition, this study evaluated only the emergency physicians' ability to distinguish between the basic stroke subtypes of hemorrhagic versus ischemic infarction. Concordance rates would be significantly lower had emergency diagnoses and hospital discharge diagnoses been compared for other stroke subtypes (eg, lacunar versus nonlacunar infarction).

A second concern is whether emergency physicians can differentiate hemorrhagic from nonhemorrhagic stroke, particularly if thrombolytic therapy is found effective for ischemic stroke.¹⁴ Studies suggest that there may be discordance between emergency physicians' and radiologists' interpretations of cranial CT scans (for stroke and nonstroke etiologies), but that few management errors occur as a result of these radiographic misinterpretations.^{14 15 16} Alfaro et al¹⁵ found that emergency physicians missed 69% of all infarcts, 62% of parenchymal hematomas, and 50% of subarachnoid hemorrhages on noncontrast cranial CTs. However, they found that none of these patients were managed inappropriately. At our institution, emergency physicians were able to identify all patients with hemorrhagic stroke based on clinical and radiographic findings (sensitivity, 100%; specificity, 100%). The majority of CT scans for this study were initially interpreted by the emergency physician alone. Hemorrhagic stroke patients may have been misdiagnosed if emergency physicians had read all the scans independently. In addition, the discrepancy between our findings and those of Alfaro et al may be due to the fact that there have been ongoing stroke trials at our institution for the last 10 years. Our emergency physicians have heightened interest and experience in urgent interpretation of CT scans performed for stroke. Further studies are needed to determine whether emergency physicians can reliably differentiate hemorrhagic stroke from nonhemorrhagic stroke based on CT findings alone.

Our study was limited to patients admitted to the hospital from the emergency department. We did not follow patients discharged from the emergency department with a diagnosis of stroke or TIA to determine whether subsequent outpatient workup confirmed a diagnosis of stroke or TIA. Potential stroke patients may have been missed if they were diagnosed with something other than stroke and discharged home from the emergency department. On review of the emergency department records, no such cases were identified. If patients with stroke were missed by this screening process, they would likely have had subtle findings or atypical presentations and therefore would not have been likely candidates for therapeutic trials.

Conclusion
Emergency physicians at a large urban teaching hospital with a comprehensive stroke intervention program can accurately identify patients with stroke, particularly hemorrhagic stroke. If similar accuracy can be documented in other types of hospitals, emergency physicians may become key providers of urgent stroke intervention.

Received June 5, 1995; revision received August 9, 1995; accepted August 31, 1995.

	References

Top Abstract Introduction Subjects and Methods Results Discussion References

 
1. Barsan WG, Brott TG, Broderick JP, Haley EC, Levy DE, Marler JR. Time of hospital presentation in patients with acute stroke. Arch Intern Med. 1993;153:2558-2561. [Abstract/Free Full Text]

2. Bratina P, Greenberg L, Pasteur W, Grotta JC. Current emergency department management of stroke in Houston, Texas. Stroke. 1995;26:409-414. [Abstract/Free Full Text]

3. Leibson CL, Naessens JM, Brown RD, Whisnant JP. Accuracy of hospital discharge abstracts for identifying stroke. Stroke. 1994;25:2348-2355. [Abstract]

4. Barsan WG, Brott TG, Olinger CP, Adams HP, Haley EC, Levy DE. Identification and entry of the patient with acute cerebral infarction. Ann Emerg Med. 1988;17:1192-1195. [Medline] [Order article via Infotrieve]

5. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency cardiac care, part IV: special resuscitation situations. JAMA. 1992;268:2242-2250. [Abstract/Free Full Text]

6. Barsan WG, Brott TG, Broderick JP, Haley EC Jr, Levy DE, Marler JR. Urgent therapy for acute stroke: effects of a stroke trial on untreated patients. Stroke. 1994;25:2132-2137. [Abstract]

7. Fisher M, Bogousslavsky J. A glimmer of hope for acute ischemic stroke. Cerebrovasc Dis. 1994;4:177-178.

8. Gomez CR. Time is brain! J Stroke Cerebrovasc Dis. 1993;3:1-2. Editorial.

9. Del Zoppo GJ, Poeck K, Pessin MS, Wolpert SM, Furlan AJ, Ferbert A, Alberts MJ, Zivin JA, Wechsler L, Busse O, Greenlee R, Brass L, Mohr JP, Feldmann E, Hacke W, Kase CS, Biller J, Gress D, Otis SM. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol. 1992;32:78-86. [Medline] [Order article via Infotrieve]

10. Zeumer H, Freitag H-J, Zanella F, Thie A, Arning C. Local intra-arterial fibrinolytic therapy in patients with stroke: urokinase versus recombinant tissue plasminogen activator (r-TPA). Neuroradiology. 1993;35:159-162. [Medline] [Order article via Infotrieve]

11. Overgaard K, Sperling B, Boysen G, Pedersen H, Gam J, Ellemann K, Karle A, Arlien-Søborg P, Olsen TS, Videbæk, Knudsen JB. Thrombolytic therapy in acute ischemic stroke: a Danish pilot study. Stroke. 1993;24:1439-1446. [Abstract/Free Full Text]

12. Ringelstein EB, Biniek R, Weiller C, Ammeling B, Nolte PN, Thron A. Type and extent of hemispheric brain infarctions and clinical outcome in early and delayed middle cerebral artery recanalization. Neurology. 1992;42:289-298. [Abstract/Free Full Text]

13. Grotta J, Clark W, Coull B, Pettigrew LC, Mackay B, Goldstein LB, Meissner I, Murphy D, LaRue L. Safety and tolerability of the glutamate antagonist CGS 19755 (Selfotel) in patients with acute ischemic stroke: results of a phase IIa randomized trial. Stroke. 1995;26:602-605. [Abstract/Free Full Text]

14. Kothari R, Brott T, Broderick JP, Gorgas DL. Emergency department thrombolytic therapy for stroke: assessing patient eligibility. Acad Emerg Med. 1994;1:A47. Abstract.

15. Alfaro D, Levitt M, English D, Williams V, Eisenberg R. Accuracy of interpretation of cranial computed tomography scans in an emergency medicine residency program. Ann Emerg Med. 1995;25:169-174. [Medline] [Order article via Infotrieve]

16. Cordovano S, Gaeta T, Spevack T, Balentine J. Accuracy of emergency department interpretation of computerized tomography of the cranium. Acad Emerg Med. 1994;1:A64. Abstract.

This article has been cited by other articles:

				T. J. Quinn, A. C. Cameron, J. Dawson, K. R. Lees, and M. R. Walters ABCD2 Scores and Prediction of Noncerebrovascular Diagnoses in an Outpatient Population: A Case-Control Study Stroke, March 1, 2009; 40(3): 749 - 753. [Abstract] [Full Text] [PDF]

				J. Dawson, K.E. Lamb, T.J. Quinn, K.R. Lees, M. Horvers, M.J. Verrijth, and M.R. Walters A recognition tool for transient ischaemic attack QJM, January 1, 2009; 102(1): 43 - 49. [Abstract] [Full Text] [PDF]

				J. A. Edlow, R. E. Rothman, and W. G. Barsan What Do We Really Know About Neurological Misdiagnosis in the Emergency Department? Mayo Clin. Proc., February 1, 2008; 83(2): 253 - 254. [Full Text] [PDF]

				J. Wachtler, P. A. Bell, and T. Brabson What Do We Really Know About Neurological Misdiagnosis in the Emergency Department? Mayo Clin. Proc., February 1, 2008; 83(2): 254 - 255. [Full Text] [PDF]

				L. R. Caplan Dizziness: How Do Patients Describe Dizziness and How Do Emergency Physicians Use These Descriptions for Diagnosis? Mayo Clin. Proc., November 1, 2007; 82(11): 1313 - 1315. [Full Text] [PDF]

				H. P. Adams Jr, G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, R. T. Higashida, E. C. Jauch, C. Kidwell, et al. Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation, May 22, 2007; 115(20): e478 - e534. [Abstract] [Full Text] [PDF]

				C.W. Kerber, I. Wanke, J. Bernard Jr., H.H. Woo, M.W. Liu, and P.K. Nelson Rapid Intracranial Clot Removal with a New Device: The Alligator Retriever AJNR Am. J. Neuroradiol., May 1, 2007; 28(5): 860 - 863. [Abstract] [Full Text] [PDF]

				H. P. Adams Jr, G. del Zoppo, M. J. Alberts, D. L. Bhatt, L. Brass, A. Furlan, R. L. Grubb, R. T. Higashida, E. C. Jauch, C. Kidwell, et al. Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists Stroke, May 1, 2007; 38(5): 1655 - 1711. [Abstract] [Full Text] [PDF]

				R. A. Shellhaas, S. E. Smith, E. O'Tool, D. J. Licht, and R. N. Ichord Mimics of Childhood Stroke: Characteristics of a Prospective Cohort Pediatrics, August 1, 2006; 118(2): 704 - 709. [Abstract] [Full Text] [PDF]

				N U Weir and A M Buchan A study of the workload and effectiveness of a comprehensive acute stroke service J. Neurol. Neurosurg. Psychiatry, June 1, 2005; 76(6): 863 - 865. [Abstract] [Full Text] [PDF]

				L. B. Morgenstern, L. D. Lisabeth, A. C. Mecozzi, M. A. Smith, P. J. Longwell, D. A. McFarling, and J. M.H. Risser A population-based study of acute stroke and TIA diagnosis Neurology, March 23, 2004; 62(6): 895 - 900. [Abstract] [Full Text] [PDF]

				S. C. Johnston, D. R. Gress, W. S. Browner, and S. Sidney Short-term Prognosis After Emergency Department Diagnosis of TIA JAMA, December 13, 2000; 284(22): 2901 - 2906. [Abstract] [Full Text] [PDF]

				J. M. Ferro, A. N. Pinto, I. Falcao, G. Rodrigues, J. Ferreira, F. Falcao, E. Azevedo, P. Canhao, T. P. Melo, M. J. Rosas, et al. Diagnosis of Stroke by the Nonneurologist : A Validation Study Stroke, June 1, 1998; 29(6): 1106 - 1109. [Abstract] [Full Text] [PDF]

				R. M. Zweifler, R. Drinkard, S. Cunningham, M. L. Brody, and J. F. Rothrock Implementation of a Stroke Code System in Mobile, Alabama : Diagnostic and Therapeutic Yield Stroke, May 1, 1997; 28(5): 981 - 983. [Abstract] [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kothari, R. U. Articles by Hamilton, C. A. Search for Related Content PubMed PubMed Citation Articles by Kothari, R. U. Articles by Hamilton, C. A.