Abstract 2869: Misdiagnosis Of Stroke Among IV tPA-treated Patients: A Two-year Experience In A Primary Stroke Center And Satellite Hospitals
Background: In the setting of acute stroke, the decision to treat a patient with IV tPA is typically based on a brief pertinent history, neurological examination, urgent labs and head CT. Because “time is brain,” the evaluation is rushed and the diagnosis is occasionally erroneous. In this study we investigated the characteristics of patients who received IV tPA when the final diagnosis was not ischemic stroke.
Methods: We conducted a retrospective study of 113 patients who presented from January 2009 to January 2011with acute stroke symptoms and received IV tPA either in our primary stroke center or one of the three satellite hospitals in our stroke network.
Results: Of 113 patients, 23 had post-tPA negative diffusion weighted images (DWI) on MRI and a discharge diagnosis other than ischemic stroke. Other discharge diagnoses included: TIA (10 cases), complicated migraine (4 cases), post-ictal Todd’s paralysis (3 cases), conversion disorder (3 cases), and toxic/metabolic encephalopathy (3 cases). The misdiagnosis rate of stroke was higher in the satellite hospitals compared to our primary stroke center (39% vs. 11%; P<.0.001). The diagnosis of acute stroke in our satellite hospitals was made by an emergency department (ED) physician after a phone consultation with one of our stroke neurologists. Other differences between patients with and without final diagnosis of stroke included: mean age (61 vs. 52 years; P<0.02), median admission NIHSS score (11 vs. 6 points; P<0.001), psychiatric co-morbidities (3% vs. 17%; P<0.05), history of hypertension (84% vs. 56%; P<0.01), and mean length of hospitalization (11 vs. 6 days; P<0.001). There were two cases of uncomplicated gingival and nose bleeding at the time of tPA infusion among patients who did not have stroke.
Conclusion: This study suggests that ED physicians working outside of the major stroke centers have difficulty distinguishing between stroke and its mimics. In the future, telemedicine may improve stroke diagnosis in satellite and rural hospitals. The results are also consistent with other studies that IV tPA causes relatively little harm in stroke mimics. Further study is warranted.
- © 2012 by American Heart Association, Inc.