Stroke Chameleons and Stroke Mimics in the Emergency Department

Liberman, Ava L; Prabhakaran, Shyam

doi:10.1007/s11910-017-0727-0

Cited by 88 publications

(63 citation statements)

References 97 publications

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“…Misdiagnosis of acute stroke may result in worse patient functional outcomes due to failure to implement acute stroke interventions as well as standard processes of care [6]. Studies have reported that 2-26% of acute stroke presentations are misdiagnosed in the emergency department (ED) [5,[7][8][9][10]. Factors contributing to stroke misdiagnosis include non-specific or atypical symptoms [5,10], such as those associated with posterior circulation stroke (PCS) [8,10,11], decreased level of consciousness [9], younger patient age [8,9,12], lower cerebrovascular disease profile [8], and transient ischemic attack (TIA) [5].…”

Section: Introductionmentioning

confidence: 99%

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

et al. 2018

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Background: Failure to recognise acute stroke may result in worse outcomes due to missed opportunity for acute stroke therapies. Our study examines factors associated with stroke misdiagnosis in patients admitted to a large comprehensive stroke centre. Methods: Retrospective review comparing 156 consecutive stroke patients misdiagnosed in emergency department (ED) with 156 randomly selected stroke controls matched for age, gender, language spoken and stroke subtype for the period 2014–2016. Results: There were 141 ischemic and 15 hemorrhagic misdiagnosed strokes (median age: 77 years, male:female = 1.3: 1). Symptom resolution, altered mental status, nausea/vomiting, dizziness and vertigo favored misdiagnosis (p < 0.05). Hemiparesis and dysarthria favored an accurate diagnosis (p < 0.05). Misdiagnosed patients were more commonly triaged into a lower ED category (62 vs. 42%, p = 0.001), clinically assessed as Face, Arm, Speech and Time (FAST) – negative (78 vs. 22%, p < 0.001) and underwent delayed CT imaging (median 4.1 vs. 1.5 h, p < 0.001). Misdiagnosed patients were more likely to have posterior circulation stroke (PCS; 39 vs. 22%, p = 0.01) and be admitted under non-neurological services (35 vs. 11%, p < 0.001) with worse discharge outcomes including increased mortality. Conclusions: Patients with stroke misdiagnosis were commonly FAST-negative with nonspecific symptoms including altered mental status, dizziness and nausea/vomiting often associated with PCS. Improved diagnostic accuracy may increase access to acute therapies.

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Section: Introductionmentioning

confidence: 99%

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

et al. 2018

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“…220 Conditions like infections, migraine, seizures, syncope, vertigo, confusional states and functional symptoms are frequent stroke mimics. [221][222][223][224] Stroke mimics lead to costly hospital admissions and are stressful for the patients and their family. 225 Recognition of stroke mimics is therefore highly important, especially in an era with constant focus on shortening the time from hospital admission to administration of thrombolysis (door-to-needle time).…”

Section: Stroke Mimics After Incident Strokementioning

confidence: 99%

“…Stroke mimic patients represent up to 40% of all patients admitted with suspected stroke. 222 Many studies have observed that patients with stroke mimics have fewer ischemic stroke risk factors. 220,226,296,297 Prior studies have quantified the incidence of stoke mimics by reporting the proportions of stroke mimics in all suspected strokes in admitted to emergency departments or stroke units.…”

Section: Stroke Mimicsmentioning

confidence: 99%

Incidence and Etiologies of Stroke Mimics After Incident Stroke or Transient Ischemic Attack

Khanevski

Kvistad

Novotný

et al. 2019

Stroke

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Background and Purpose— Stroke mimics (SM) pose a common clinical challenge, but the burden of SM in patients with previous ischemic stroke (IS) or transient ischemic attack is unknown. The objective of this study was to calculate the incidence of SM in IS survivors, compare it with the incidence of recurrent stroke in the same population, and explore the time-dependent patterns of SM etiologies. Methods— This prospective cohort study registered SM events and etiologies among 1872 IS and transient ischemic attack survivors diagnosed with index stroke at Haukeland University Hospital stroke unit from 2007 to 2013 by review of medical records. Cumulative incidences of SM were estimated with a competing risks Cox model and compared with incidence of recurrent stroke in the same population. Results— During 8172 person-years of follow-up, 339 patients had 480 SM events. The cumulative incidence rate of SM during follow-up was 58.7 per 1.000 person-years (95% CI, 53.7–64.2) compared with 34.0 per 1.000 person-years (95% CI, 30.2–38.2) for recurrent stroke in the same time period. The risks of SM and recurrent stroke were highest the first year after index IS or transient ischemic attack. The most frequent SM diagnoses were sequelae of cerebral infarction (19.8%), medical observation, and evaluation for suspected cerebrovascular disease (15.6%) and infections (14.0%). The 2 most frequent and unspecific diagnoses (sequelae of cerebral infarction and medical observation) were clustered in the first months after index stroke. Conclusions— SM after IS or transient ischemic attack are more frequent than recurrent stroke and the risk is especially high in the early period. SMs are multietiological and unspecific diagnoses are most frequent early after index stroke.

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“…Refieren que la paciente ha manifestado ideas de muerte y en la última semana presentó problemas familiares. alteracion del estado de conciencia, tener en cuenta, estudiar y descartar el accidente cerebrovascular (ACV) isquémico, ya que esta condición está descrita como uno de los principales síntomas camaleónicos, que son aquellas condiciones en donde un ACV puede simular una patología alternativa 16,17 . De los pacientes que ingresan con alteracion en el estado de conciencia sin evidencia de focalización, hasta en el 70% de los casos el diagnóstico de ACV no se realiza de forma correcta 18 .…”

Section: Caso Clínicounclassified

“…Por los síntomas y la presencia de ataxia, disartria con posterior alteración en el estado de conciencia, así como por el nistagmus vertical, era importante realizar RMN que es más sensible para evidenciar compromiso en fosa posterior 20 . Varios estudios han reportado que los síntomas camaleónicos del ACV son más probables en circulación posterior, siendo este compromiso el que más frecuentemente se pasa por alto y es mal diagnosticado en urgencias, por lo que es de vital importancia en los pacientes con este tipo de presentaciones realizar el examen físico completo con énfasis en el SNC y efectuar estudios con imágenes más avanzadas 16,21 .…”

Section: Caso Clínicounclassified

Toxidrome sedante versus enfermedad cerebrovascular: a propósito de un caso

Maldonado¹,

Mejía

2018

MedUPB

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RESUMENDescribimos el caso de una paciente femenina con signos y síntomas iniciales poco específicos, con alteración en el estado de conciencia. Se sospechó posible intoxicación, por nexo causal, probablemente por amitraz versus benzodiacepinas, sin embargo, sin confirmación de este. La paciente tenía alteración del sistema nervioso central con sín-tomas sugestivos de síndrome neurovascular, con posible compromiso de circulación posterior. La importancia de este caso es resaltar el amplio espectro de presentación clínica de las enfermedades neurológicas, la importancia de realizar diagnósticos diferenciales considerando los síntomas camaleónicos del accidente cerebrovascular, al igual que los "mimics stroke" y realizar enfoques clínicos integrales. Palabras clave: trastornos de la conciencia; accidente cerebrovascular; diagnóstico diferencial. ABSTRACTDescription of the case of a female patient that presented non-specific initial signs and symptoms, with altered mental status, suggestive signs of neuro-vascular syndrome, and compromise of posterior circulation. Possible intoxication with amitraz or benzodiazepines was considered due to personal history and family reports. Given the chameleonic nature of the symptoms of cerebrovascular accidents and stroke mimics, this clinical case exposes the importance of a comprehensive approach and evaluation of possible differential diagnoses of neurological diseases.

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Stroke Chameleons and Stroke Mimics in the Emergency Department

Cited by 88 publications

References 97 publications

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

Incidence and Etiologies of Stroke Mimics After Incident Stroke or Transient Ischemic Attack

Toxidrome sedante versus enfermedad cerebrovascular: a propósito de un caso

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