Backgrounds Given the short therapeutic window for evidence‐based therapies such as thrombolysis and endovascular treatment, it is important to immediately diagnose ischemic stroke. We investigated the prevalence of missed ischemic stroke diagnoses at initial contact and the proportion of potentially treatable patients without a delayed diagnosis. Methods A cross‐sectional study was conducted. A total of 408 consecutive patients hospitalized due to acute ischemic stroke were included. The primary outcome was a delayed diagnosis of ischemic stroke at initial contact. A diagnosis of stroke was judged to be delayed unless physicians made a diagnosis and initiated treatment for ischemic stroke during the initial contact. The secondary outcome was ischemic stroke with a missed therapeutic window for effective treatment due to delayed diagnosis. Results The median patient age was 78 years old, and the median time from onset to presentation was nine hours. A diagnosis of stroke was deemed delayed in 49 (12.0%) patients. In the multivariable analysis, presentation 48 hours or more after stroke onset (OR 2.45) and the improvement of neurological symptoms prior to presentation (OR 3.11) were independently associated with delayed diagnosis of ischemic stroke. Opportunities for effective treatment were missed in 18 (36.7%) of the 49 delayed diagnosis cases, although no patients missed opportunities for thrombectomy due to delayed diagnosis. Conclusions Even in the modern era, one out of every eight ischemic stroke cases was missed at the initial visit, and one‐third of missed stroke cases might be candidates for effective treatment without diagnostic delay.

No abstract

No abstract

An 81-year-old woman presented to the emergency department with a 2-week history of malaise, fever and anorexia, with oral pain and odynophagia. Her medical history was remarkable only for type 2 diabetes mellitus. She was not taking any immunosuppressive agents. Her body temperature was 37.7°C, and other vital signs were normal. Physical examination showed multiple yellowish-white, pseudomembranous lesions on the patient's tongue (Figure 1A). The rest of the physical examination was unremarkable. Esophagogastroduodenoscopy showed multiple shallow ulcers with a white coating (Figure 1B and Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/ cmaj .210352/tab-related-content). Glossal and esophageal biopsies showed multinucleated cells with moulded, groundglass nuclei (Appendix 2, available at www.cmaj.ca/lookup/ doi/10.1503/cmaj.210352/tab-related-content). Results from polymerase chain reaction and immunohistochemical staining of the specimens were positive for herpes simplex virus type 1 (HSV-1), and we diagnosed herpetic glossitis and esophagitis. We did not find any evidence of malignant disease on a whole body computed tomography scan and upper and lower endoscopy. The patient's HIV test result was negative and her hemoglobin A 1c was 7.2%. We treated her with a 7-day course of acyclovir, intravenously because of her odynophagia, and the oral and esophageal lesions completely resolved.Herpes labialis is the most common manifestation of HSV-1 infection, accounting for about 90% of reactivated infections. 1 In contrast, herpetic glossitis and esophagitis are uncommon manifestations of HSV-1 infection. The macroscopic findings of herpetic glossitis are diverse, including single or multiple vesicles, ulcers, linear or crosshatched fissures and pseudotumoral plaques, as with our patient. 2 The differential diagnosis includes oral candidiasis, syphilis, tuberculosis, pemphigus, lichen planus and hairy leukoplakia. 3 Herpetic glossitis can coexist with herpetic esophagitis, and esophagogastroscopy should be considered if the patient has odynophagia. Herpetic esophagitis characteristically manifests as well-circumscribed ulcers that are sometimes described as having a volcano-like appearance (Appendix 1). 4 Diagnosis of herpetic glossitis and esophagitis can be made clinically if the presentation is typical; otherwise, virological confirmation is necessary to differentiate the disease from other entities. 1 Treatment consists mainly of antiviral agents, including acyclovir, valacyclovir and famciclovir, after considering the patient's immune status and disease severity.