Transient Ischemic Attack after Tissue Plasminogen Activator: Aborted Stroke or Unnecessary Stroke Therapy?

Uchino, Ken; Massaro, Lori; Hammer, Maxim D.

doi:10.1159/000255975

Cited by 43 publications

(47 citation statements)

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“…While our proportion of SMs is in line with other studies, our proportion of neuroimagingnegative strokes is somewhat higher than other series of patients treated with IV tPA. 12,14 The strengths of our study include a fairly large sample of language discordant encounters. In addition, our mostly linguistically homogeneous non-English-speaking population allows exploration of the role of language discordance in acute stroke treatment among Spanish speakers.…”

Section: Discussionmentioning

confidence: 99%

Language barriers between physicians and patients are not associated with thrombolysis of stroke mimics

et al. 2016

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Background: Acute stroke is a time-sensitive condition in which rapid diagnosis must be made in order for thrombolytic treatment to be administered. A certain proportion of patients who receive thrombolysis will be found on further evaluation to have a diagnosis other than stroke, so-called "stroke mimics." Little is known about the role of language discordance in the emergency department diagnosis of acute ischemic stroke. Methods: This is a retrospective analysis of all acute ischemic stroke patients who received IV tissue plasminogen activator (tPA) in our emergency department between July 2011 and December 2015. Baseline characteristics, patient language, and final diagnosis were compared between encounters in which the treating neurologist and patient spoke the same language (concordant cases) and encounters in which they did not (discordant cases). Results: A total of 350 patients received IV tPA during the study period. English was the primary language for 52.6%, Spanish for 44.9%, and other languages for 2.6%; 60.3% of cases were classified as language concordant and 39.7% as discordant. We found no significant difference in the proportion of stroke mimics in the language concordant compared to discordant groups (16.6% vs 9.4%, p 5 0.06). Similarly, the proportion of stroke mimics did not differ between English-and Spanish-speaking patients (15.8% vs 11.5%, p 5 0.27). Conclusions: Language discordance was not associated with acute stroke misdiagnosis among patients treated with IV tPA. Prospective evaluation of communication during acute stroke encounters is needed to gain clarity on the role of language discordance in acute stroke misdiagnosis. Neurol Clin Pract 2016;6:389-396 L anguage discordance occurs when a patient and treating physician do not have proficiency in the same language and has been associated with decreased quality of acute care.1-3 However, little is known about the role of language discordance in the emergency department (ED) diagnosis of acute ischemic stroke (AIS).

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Section: Discussionmentioning

confidence: 99%

Language barriers between physicians and patients are not associated with thrombolysis of stroke mimics

et al. 2016

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“…Estas patologías que se presentan simulando un ictus pero que tras estudio se demuestra su diferente etiología son conocidas como imitadoras del ictus o pseudoictus (PI). En los servicios de urgencias hospitalarios (SUH) los PI representan de un 20 a un 30% de los pacientes ingresados con diagnóstico de ictus en un primer momento 1 , así como de un 1,4 a un 15% de los pacientes que reciben trombolisis con activador recombinante del plasminógeno tisular (rt-PA iv) tienen un diagnóstico final de PI [2][3][4][5][6][7][8][9] . La etiología es muy variada e incluye hematoma subdural, migraña, crisis comiciales, tumores, infecciones, esclerosis múltiple, trastornos somatomorfo 10 , delirio, etc [1][2][3][4][5][6][7][8][9][11][12][13][14][15][16][17] .…”

Section: Introductionunclassified

“…En los servicios de urgencias hospitalarios (SUH) los PI representan de un 20 a un 30% de los pacientes ingresados con diagnóstico de ictus en un primer momento 1 , así como de un 1,4 a un 15% de los pacientes que reciben trombolisis con activador recombinante del plasminógeno tisular (rt-PA iv) tienen un diagnóstico final de PI [2][3][4][5][6][7][8][9] . La etiología es muy variada e incluye hematoma subdural, migraña, crisis comiciales, tumores, infecciones, esclerosis múltiple, trastornos somatomorfo 10 , delirio, etc [1][2][3][4][5][6][7][8][9][11][12][13][14][15][16][17] . Estudios recientes han identificado las características clínicas y radiológicas asociadas a un diagnóstico final de PI incluyendo signos vitales, síntomas clínicos, signos neurológicos, gravedad del ictus e incluso las secuelas neurológi-cas al alta 2,4,5,11,15,18 .…”

Section: Introductionunclassified

Imitadores del ictus: un reto para el médico de urgencias

Valle

Lopera

Guillán

et al. 2014

Anales Sis San Navarra

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resuMenFundamento. Estudiar el número de pacientes diagnosticados de ictus en el servicio de urgencias hospitalario de un hospital de primer nivel y la proporción de estos pacientes que finalmente eran pseudoictus, así como describir y analizar las variables que pueden ayudar en el diagnóstico diferencial en los servicios de urgencias hospitalarios.Método. Estudio prospectivo de 9 meses. Se incluyeron todos los pacientes valorados en el servicio de Urgencias e ingresados con el diagnóstico de ictus. Se analizaron diversas variables clínicas que incluían la historia previa, la historia del evento actual, el examen físico general y neurológico y la clasificación del NIHSS y de la Oxforshire Community Stroke. El diagnóstico final se realizó por un panel de expertos con acceso a las características clínicas, estudios de imagen y otras pruebas. El análisis univariante y multivariado determinó las características que ayudan a distinguir los ictus de los pseudoictus.resultados. Se registraron 144 casos de ictus; la muestra final la conformó 140 pacientes. El diagnóstico final fue de ictus en 103 de 140 (73,6%) y de pseudoictus en el resto. Once variables predecían el diagnóstico en pacientes que se presentaban con sospecha de ictus: la edad superior a 70 años (p=0,012), una clasificación del NIHSS > 5, lograr una clasificación clínica (p=0,019) capaz de determinar el comienzo exacto (p=0,000), hallazgos vasculares anormales (p=0,014), desviación de la mirada (p=0.042), pérdida de la visión (p=0,052) y reflejo plantar extensor (p=0,025) favorecían el diagnóstico de ictus, mientras que las crisis comiciales (p=0,029), los síntomas neurológicos no congruentes con el territorio vascular (p=0,022) y los hallazgos anormales en otros sistemas (p=0,14) favorecían el diagnostico de pseudoictus.conclusión. Los pseudoictus constituyeron un tercio de los pacientes ingresados desde el servicio de Urgencias como ictus siendo la etiología muy variada. Lograr una historia clínica adecuada y un examen físico preciso es de gran importancia y puede ayudar a facultativos menos experimentados.Palabras claves. Pseudoictus. Ictus. Diagnóstico. abstract background. To study the number of patients diagnosed with a stroke in the emergency service of a first level hospital and the proportion of these patients who were finally stroke mimics, as well as to describe and analyze the variables that can help in differential diagnosis in hospital emergency services.

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“…However, the efforts to increase the availability of IVT and to reduce the time of delivery of tissue-type plasminogen activator (tPA) carry the potential for administering IVT in patients with a noncerebrovascular etiology for their acute neurological deficits that "mimic" AIS. 1,2 Despite the high prevalence of stroke mimics (SMs) among patients presenting acutely to emergency department with suspected or initially diagnosed stroke, 3 limited data exist regarding the use of IVT in patients erroneously diagnosed as having AIS in the emergency department. 4 -6 We aimed to determine the safety of thrombolysis and to describe outcomes in SM using the 6-year experience of our tertiary care center and also by performing a pooled analysis of available published data.…”

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Safety and Outcomes of Intravenous Thrombolysis in Stroke Mimics

Tsivgoulis

Alexandrov

Chang

et al. 2011

Stroke

127

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Background and Purpose-Efforts to increase the availability and shorten the time delivery of intravenous thrombolysis in patients with acute ischemic stroke carry the potential for tissue plasminogen activator administration in patients with diseases other than stroke, that is, stroke mimics (SMs). We aimed to determine safety and to describe outcomes of intravenous thrombolysis in SM. Methods-We retrospectively analyzed stroke registry data of consecutive acute ischemic stroke admissions treated with intravenous thrombolysis over a 6-year-period. The admission National Institutes of Health Stroke Scale score, vascular risk factors, ischemic lesions on brain MRI (routinely performed as part of diagnostic work-up), and discharge modified Rankin Scale scores were documented. Initial stroke diagnosis in the emergency department was compared with final discharge diagnosis. SM diagnosis was based on the absence of ischemic lesions on diffusion-weighted imaging sequences in addition to an alternate discharge diagnosis. Symptomatic intracranial hemorrhage was defined as brain imaging evidence of intracranial hemorrhage with clinical worsening by National Institutes of Health Stroke Scale score increase of Ն4 points. Results-Intravenous thrombolysis was administered in 539 patients with acute ischemic stroke (55% men; mean age, 66Ϯ15 years). Misdiagnosis of acute ischemic stroke was documented in 56 cases (10.4%; 95% CI, 7.9% to 13.3%). Conversion disorder (26.8%), complicated migraine (19.6%), and seizures (19.6%) were the 3 most common final diagnoses in SM. SMs were younger (mean age, 56Ϯ13 years) and had milder baseline stroke severity (median National Institutes of Health Stroke Scale, 6; interquartile range, 4) compared with patients with confirmed acute ischemic stroke (mean age, 67Ϯ14 years; median National Institutes of Health Stroke Scale, 8; interquartile range, 10; PϽ0.001). There was no case of symptomatic intracranial hemorrhage in SMs (0%; 95% CI, 0% to 5.5%); 96% of SMs were functionally independent at hospital discharge (modified Rankin Scale, 0 to 1). Conclusions-Our single-center data indicate favorable safety and outcomes of intravenous thrombolysis administered to SM. (Stroke. 2011;42:1771-1774.)

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Transient Ischemic Attack after Tissue Plasminogen Activator: Aborted Stroke or Unnecessary Stroke Therapy?

Cited by 43 publications

References 20 publications

Language barriers between physicians and patients are not associated with thrombolysis of stroke mimics

Language barriers between physicians and patients are not associated with thrombolysis of stroke mimics

Imitadores del ictus: un reto para el médico de urgencias

Safety and Outcomes of Intravenous Thrombolysis in Stroke Mimics

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