Predictors of neurologists confirming or overturning emergency physicians' diagnosis of TIA or stroke

Abstract

Background Transient ischemic attack (TIA) and non-disabling stroke are common emergency department (ED) presentations. Currently, there are no prospective multicenter studies determining predictors of neurologists confirming a diagnosis of cerebral ischemia in patients discharged with a diagnosis of TIA or stroke. The objectives were to (1) calculate the concordance between emergency physicians and neurologists for the outcome of diagnosing TIA or stroke, and (2) identify characteristics associated with neurologists diagnosing a stroke mimic. Methods This was a planned sub-study of a prospective cohort study at 14 Canadian EDs enrolling patients diagnosed with TIA or non-disabling stroke from 2006 to 2017. Logistic regression was used to identify factors associated with neurologists' diagnosis of cerebral ischemia. Our primary outcome was the composite outcome of cerebral ischemia (TIA or non-disabling stroke) based on the neurologists' assessment. Results The diagnosis of cerebral ischemia was confirmed by neurologists in 5794 patients (55.4%). The most common identified stroke mimics were migraine (18%), peripheral vertigo (7%), syncope (4%), and seizure (3%). Over a third of patients (38.4%) ultimately had an undetermined aetiology for their symptoms. The strongest predictors of cerebral ischemia confirmation were infarct on CT (

Transient ischemic attack and minor stroke: diagnosis, risk stratification and management

“…Common mimics of TIA or minor stroke include migraine, peripheral vertigo, syncope, somatization and seizure. 10 Symptoms more commonly seen in patients with a stroke mimic include loss of consciousness, vertigo, bilateral symptoms and confusion. 10 Because the resources available to urgently risk-stratify patients for the likelihood of subsequent stroke are limited, physicians should carefully consider other diagnoses before starting such investigations.…”

“…10 Symptoms more commonly seen in patients with a stroke mimic include loss of consciousness, vertigo, bilateral symptoms and confusion. 10 Because the resources available to urgently risk-stratify patients for the likelihood of subsequent stroke are limited, physicians should carefully consider other diagnoses before starting such investigations. Some hospitals routinely order an urgent MRI scan given that the longer symptoms are present, the more likely there will be acute ischemic changes on MRI.…”

“…19 Given that about half of patients suspected of TIA or stroke actually have a stroke mimic as the cause of their symptoms, it is not a good use of resources to urgently seek imaging for all low-risk patients. 10 These patients can either forgo imaging or have imaging performed within days after their index event, depending on the likelihood of the primary event being a true TIA or stroke.…”

“…8,9 About half of initial diagnoses of TIA or minor stroke are ultimately diagnosed as a stroke mimic. 10 Once patients are determined to have TIA or minor stroke, a series of investigations and assessments are needed to ascertain the cause as this determines management. Making an accurate diagnosis and identifying high-risk patients in a timely manner is critical to decrease the likelihood of a subsequent event.…”

Accident ischémique transitoire et AVC mineur: diagnostic, stratification du risque et prise en charge

“…Outre les questions de nomenclature, les médecins doivent établir une liste de diagnostics différentiels imitant l'AVC (c.-à-d., qui font penser à un AIT ou à un AVC mineur) et mettre en place des mesures de prévention de l'AVC en présence d'un risque 8,9 . Environ la moitié des diagnostics initiaux d'AIT ou d'AVC mineur se transforment éventuellement en diagnostics différentiels imitant l'AVC 10 .…”