Letter by Radecki Regarding Article, “Safety of Thrombolysis in Stroke Mimics: Results From a Multicenter Cohort Study”
To the Editor:
It is with great interest I read the recent publications regarding identification and treatment of stroke mimics (SM). Zinkstok et al1 describe an exceedingly low incidence of SM treated with thrombolytic therapy in their multicenter cohort, atypical of other published literatures. Guerrero et al,2 in their editorial, comment this low incidence is likely the result of very narrow criteria for diagnosis of SM, requiring the presence of a convincing alternative diagnosis. Furthermore, Guerrero et al2 suggest the lack of use of magnetic resonance imaging (MRI) with diffusion-weighted sequences (DWI) as a confirmatory study impaired their ability to discriminate acute ischemic stroke (AIS) from SM.
Guerrero et al2 also suggest a role for DWI MRI to document the incidence of averted stroke. However, the findings by Freeman et al3 seem to indicate, unsurprisingly, that thrombolytic therapy does not result in resolution of DWI MRI lesions in AIS. This casts doubt on the premise of neuroimaging negative cerebral ischemia4 representing averted stroke after thrombolytic therapy. Rather, these patients ought be considered likely SM and possible misdiagnosis of AIS. The ramification for these findings may be substantial underestimation of the rate of SM. The true incidence of SM treated with thrombolytic therapy likely ranges between 6.5% and 15.5% at academic centers, as reported by those using DWI MRI in the literature review by Zinkstok et al.1 Certainly, the rate of SM will be higher in community settings, likely approaching the 25% to 29% noted by Guerrero et al.2
It has been repeatedly demonstrated the incidence of life-threatening complications from thrombolytic treatment is very low in SM, where the structural integrity of cerebrovascular tissue is not typically compromised. However, the difficult question of the acceptable rate of misdiagnosis remains—particularly in the context of widespread initiatives to streamline and expand treatment. These misdiagnosed patients are exposed only to costs and potential harms from inappropriate thrombolytic therapy, as well as, as suggested by Freeman et al,3 the downstream harms of being incorrectly labeled with a diagnosis of AIS.
In the context of findings of Freeman et al,3 perhaps it would be prudent for the National Quality Foundation endorsed performance measure for thrombolytic therapy5 require patients receiving thrombolysis for AIS undergo confirmatory testing, such as DWI MRI, and report the incidence of neuroimaging negative events. It is unethical to expand our efforts to be swift without simultaneously measuring any degradation in accuracy.
Ryan P. Radecki, MD
Department of Emergency Medicine
The University of Texas Health Science Center at Houston
Sources of Funding
Dr Radecki is supported by a training fellowship from the Keck Center of the Gulf Coast Consortia, on the Training Program in Patient Safety and Quality, Agency for Healthcare Research and Quality T32HS017586.
Stroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited.
- © 2013 American Heart Association, Inc.
- Zinkstok SM,
- Engelter ST,
- Gensicke H,
- Lyrer PA,
- Ringleb PA,
- Artto V,
- et al
- Guerrero WR,
- Savitz SI
- Freeman JW,
- Luby M,
- Merino JG,
- Latour LL,
- Auh S,
- Song SS,
- et al
- 5.↵The Joint Commission. 2012. Specifications manual for national hospital inpatient quality measures. http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx. Accessed May 3, 2013.