scholarly journals 01 Development and validation of a pragmatic prehospital tool to identify stroke MIMIC patients

2019 ◽  
Vol 36 (1) ◽  
pp. e1.1-e1
Author(s):  
Graham McClelland ◽  
Darren Flynn ◽  
Helen Rodgers ◽  
Chris Price
Keyword(s):  
Clinical Characteristics ◽  
List Type ◽  
Stroke Patients ◽  
Stroke Mimics ◽  
Primary Hospital ◽  
Stroke Services ◽  
Suspected Stroke ◽  
Stroke Mimic ◽  
High Level ◽  
Development And Validation

BackgroundStroke mimics (SM) are non-stroke conditions producing similar symptoms to stroke. Prehospital stroke identification tools prioritise sensitivity over specificity, therefore >25% of prehospital suspected stroke patients are SM. Failure to identify SM Results in inefficient use of ambulances and specialist stroke services. We developed a pragmatic tool for paramedics, using information often available in the prehospital setting, to identify SM amongst suspected stroke patients.MethodsThe initial tool was developed using a systematic literature review to identify SM characteristics, a survey of UK paramedics to explore the acceptability of SM identification and regression analysis of clinical variables documented in ambulance records of suspected stroke patients linked to their primary hospital diagnoses (n=1,650, 40% SM).The initial tool was refined using two focus groups with paramedics (n=3) and hospital clinicians (n=9) and analysis of an expanded prehospital dataset (n=3,797, 41% SM) to produce the final STEAM tool.ResultsSTEAM scores six variables:1 point for Systolic blood pressure <90 mmHg1 point for Temperature >38.5°C with heart rate >90 bpm1 point for seizures or 2 points for seizures with diagnosed Epilepsy1 point for Age <40 years or 2 points for age <30 years1 point for headache with diagnosed Migraine1 point for FAST–veA score of ≥2 on STEAM predicted SM diagnosis in the expanded derivation dataset with 5.5% sensitivity, 99.6% specificity and positive predictive value (PPV) of 91.4%. STEAM was validated using an external dataset (n=1,848, 33% SM) of prehospital suspected stroke patients where STEAM was 5.5% sensitive, 99.4% specific with a PPV of 82.5%.ConclusionsSTEAM uses common clinical characteristics to identify a small number of SM patients with a high level of certainty. The benefits of reducing SM admissions to specialist stroke services should be weighed against delayed admission for the small number of stroke patients identified as a SM.

120 Prospective study determining the predictive value of inattention in the evaluation of suspected acute stroke; a territory wide study

2019 ◽  
Vol 90 (e7) ◽  
pp. A39.1-A39
Author(s):  
Jonathan JD Baird-Gunning ◽  
Shaun Zhai ◽  
Brett Jones ◽  
Neha Nandal ◽  
Chandi Das ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Predictive Value ◽  
Strong Predictor ◽  
Large Vessel ◽  
List Type ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Predictive Values ◽  
Stroke Mimics

Introduction25%-30% of patients admitted with acute stroke are stroke mimics. Clinical assessment plays a major role in diagnosis in the hyperacute clinical setting. Identifying physical signs that correctly identify stroke is therefore important. A retrospective study1 suggested that the presence of sensory inattention (or neglect) was seen exclusively in stroke patients, suggesting that inattention might be a reliable discriminator between stroke and mimics. This study aimed to test that hypothesis.MethodsProspective assessment of suspected stroke patients for the presence of neglect (NIHSS definition). Neglect could be visual and/or somatosensory. The presence of neglect was then correlated with eventual diagnosis at 48 hours. Sensitivity, specificity and predictive values were calculated. A post-hoc analysis evaluated the correlation of neglect with large vessel occlusion in patients who underwent angiography.Results115 patients were recruited, 70 ultimately with stroke and 45 with other diagnoses. Neglect was present in 27 patients (of whom 23 had stroke) and absent in 88. This yielded: sensitivity 32.9%, specificity 91.1%, positive predictive value 85.2%, and negative predictive value 41.9%. Two patients with neglect had a diagnosis of functional illness, one a seizure, and one a brain tumour. Neglect was present in 7 out of 8 patients with large vessel occlusion (sensitivity 87.5%) and was absent in all patients who did not have large vessel occlusion on angiogram.ConclusionWhen present, neglect is a strong predictor of organic pathology and large vessel occlusion. However, it is not 100% specific and can be seen in functional presentations.ReferenceGargalas S, Weeks R, Khan-Bourne N, Shotbolt P, Simblett S, Ashraf L, Doyle C, Bancroft V, David AS: Incidence and outcome of functional stroke mimics admitted to a hyperacute stroke unit. J Neurol Neurosurg Psychiatry 2017, 88:2–6.

Abstract WP395: Can Nursing-driven Stroke Alert Activations be Effective?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Nicole L Anderson ◽  
Amy L Castle ◽  
Ganesh Asaithambi
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Treatment Delays ◽  
Stroke Mimics ◽  
Intravenous Alteplase ◽  
Stroke Mimic ◽  
High Level ◽  
The Impact

Background: Earlier stroke alert activations in the emergency department can assemble needed resources quickly in order to shorten treatment delays among eligible patients. We compared the impact of nursing-driven stroke alert activations to EMS- or physician-directed stroke alert activations. Methods: From January 2015 to June 2016, we reviewed data from all emergency department stroke alert activations at an acute stroke ready hospital. We compared nursing (RN)-driven to paramedic (EMS)- and physician (MD)-driven stroke alert activations to determine rates of stroke mimic diagnoses at discharge and use of intravenous alteplase as well as median door-to-stroke alert, door-to-CT, and door-to-needle times. Results: There were 175 stroke alert activations during the study period (42 RN, 87 pre-hospital, 46 MD). Stroke mimics prompting stroke alert activations were not significantly different between RN- and EMS-activations (26.2% RN vs 34.5% EMS, p=0.42) but was significantly higher for MD activations (50% MD, p=0.04). Compared to RN-activations, EMS-activations had shorter door to stroke alert (-7 [-10, -5] minutes EMS vs 4 [1, 7] minutes RN, p<0.01) and door to CT (0 minutes EMS vs 14 [8, 16] minutes RN, p<0.01) times; MD-activations had longer door to stroke alert (11.5 [6, 22] minutes MD, p<0.01) and door to CT (20.5 [14, 30.75] minutes MD, p<0.01). Door-to-needle times were similar between RN- and MD-activations (51 [38, 54] minutes RN vs 58 [49, 63] MD, p=0.25); there was a trend towards quicker DNTs for EMS-activations (39 [31, 43] minutes EMS, p=0.057). Rates of alteplase usage were similar for RN-activations (19%) compared to EMS- (12.6%, p=0.43) and MD- (23.9%, p>0.99) activations. Conclusion: Because of a high level of accuracy, nursing-driven stroke alert activations should be encouraged if indicated in order to shorten stroke alert time metrics when pre-hospital alerts have not occurred. Further studies are needed to examine the impact of nursing-driven stroke alert activations.

Abstract WP238: Thrombolytic Use in Stroke Mimics via Telestroke

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Ganesh Asaithambi ◽  
Amy L Castle ◽  
Michael A Sperl ◽  
Aditi Gupta ◽  
Jayashree Ravichandran ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Rehabilitation Unit ◽  
Stroke Mimics ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Stroke Mimic ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Acute Rehabilitation

Background: It has been established that safety and outcomes of intravenous thrombolysis (IVT) to stroke patients via telestroke (TS) is similar to those presenting to stroke centers. Little is known on the accuracy of TS diagnosis among those receiving IVT. We sought to compare the rate of stroke mimic (SM) patients receiving IVT in our TS network to those who present to our comprehensive stroke center (CSC). Methods: Consecutive patients receiving IVT between August 2014 and June 2015 were identified at our CSC and TS network. The rates of SM patients in each cohort were calculated. Outcomes measured included rates of symptomatic intracerebral hemorrhage (sICH), in-hospital mortality, and discharge to home or an acute rehabilitation unit (ARU). Results: During the study period, 132 patients (mean age 71±15 years, 49% women) receiving IVT were included in the analysis (75 CSC, 57 TS). Rates of SM patients receiving IVT were similar (CSC 12% vs TS 7%, p=0.39). One stroke patient developed sICH, and three other stroke patients experienced in-hospital mortality; neither outcome was found in the SM cohort. Discharge to home or ARU was similar between stroke (76.5%) and SM (76.9%) patients (p=1). Patients with SMs had significantly higher diagnoses of migraine (p=0.045) and psychiatric disorders (p=0.0002) compared to stroke patients. Conclusion: The rate of IVT among SM patients via TS is low and similar to those who present directly to a stroke center. Continued efforts should be made to further minimize IVT in SM patients despite the low rate of complications.

Abstract WP340: Is There a Ceiling Effect For EMS Stroke Diagnostic Accuracy?

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Diane Handler ◽  
Catherine Kane ◽  
Michelle Wehr ◽  
Anne W Alexandrov
Keyword(s):  
Diagnostic Accuracy ◽  
Formal Education ◽  
Hospital Setting ◽  
Report Card ◽  
Ceiling Effect ◽  
Stroke Patients ◽  
Chi Square ◽  
Continuous Feedback ◽  
Suspected Stroke ◽  
Stroke Mimic

Background: The accuracy of paramedic diagnosis of stroke is essential to the American Heart Association’s Stroke Chain of Survival. The highest rate of stroke diagnostic accuracy reported in the literature is 79% (Wojner-Alexandrov et al, 2005) and resulted from continuous feedback education. We aimed to see whether an EMS Report Card intervention could achieve similar results in a rural community hospital setting. Methods: Consecutive EMS-diagnosed stroke patients were evaluated by the Stroke Team. An EMS Report Card was developed to provide feedback on all suspected stroke patients and formal education was provided based on trends in EMS reports to support improved diagnostic accuracy. Results: A total of 198 EMS diagnosed Stroke Alerts were analyzed; 41 were admitted in 2009, 83 in 2010, 74 in 2011. The rate of stroke mimic transports for EMS was 29% in 2009 (sensitivity=71%), and improved to 26% in 2010 (sensitivity=73%), and improved to 23% by 2011 (sensitivity=77%). Specificity was not calculated. Table 1 shows the frequency of stroke mimic diagnoses for this 3 year period. The number of EMS admissions treated with intravenous tPA was 8 for 2009 (door to bolus time 55.6 minutes + 21.7, median 60.5 minutes, range 25-84 minutes), 22 for 2010 (door to bolus time 52.1 minutes + 14.5, median 50.5 minutes, range 20-90 minutes), and 17 for 2011 (door to bolus time 50.8 minutes + 18.3, median 51 minutes, range 28-68 minutes). The number of intravenous tPA treatments, and door to bolus time were not significantly different over the 3 year period. There was a trend towards increased tPA treated patients by EMS squad (Chi Square=23.3; p=0.078). Conclusion: Accuracy of stroke paramedic diagnosis is important. While our intervention did not demonstrate further improvement, this may indicate a ceiling effect for paramedic stroke diagnostic accuracy above 77-79% that should be considered acceptable.

scholarly journals Purines for Rapid Identification of Stroke Mimics (PRISM): study protocol for a diagnostic accuracy study

2021 ◽  
Vol 5 (1) ◽  
Author(s):  
Lisa Shaw ◽  
Sara Graziadio ◽  
Clare Lendrem ◽  
Nicholas Dale ◽  
Gary A. Ford ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Optimal Threshold ◽  
Receiver Operating Curve ◽  
Index Test ◽  
Predictive Values ◽  
Stroke Population ◽  
Stroke Services ◽  
Hospital Population ◽  
Suspected Stroke ◽  
Stroke Mimic

Abstract Background Rapid treatment of stroke improves outcomes, but accurate early recognition can be challenging. Between 20 and 40% of patients suspected to have stroke by ambulance and emergency department staff later receive a non-stroke ‘mimic’ diagnosis after stroke specialist investigation. This early diagnostic uncertainty results in displacement of mimic patients from more appropriate services, inappropriate demands on stroke specialist resources and delayed access to specialist therapies for stroke patients. Blood purine concentrations rise rapidly during hypoxic tissue injury, which is a key mechanism of damage during acute stroke but is not typical in mimic conditions. A portable point of care fingerprick test has been developed to measure blood purine concentration which could be used to triage patients experiencing suspected stroke symptoms into those likely to have a non-stroke mimic condition and those likely to have true stroke. This study is evaluating test performance for identification of stroke mimic conditions. Methods Design: prospective observational cohort study Setting: regional UK ambulance and acute stroke services Participants: a convenience series of two populations will be tested: adults with a label of suspected stroke assigned (and tested) by attending ambulance personnel and adults with a label of suspected stroke assigned at hospital (who have not been tested by ambulance staff). Index test: SMARTChip Purine assay Reference standard tests: expert clinician opinion informed by brain imaging and/or other investigations will assign the following diagnoses which constitute the suspected stroke population: ischaemic stroke, haemorrhagic stroke, TIA and stroke mimic conditions. Sample size: ambulance population (powered for mimic sensitivity) 935 participants; hospital population (powered for mimic specificity) 377 participants. Analyses: area under the receiver operating curve (ROC) and optimal sensitivity, specificity, and negative and positive predictive values for identification of mimic conditions. Optimal threshold for the ambulance population will maximise sensitivity, minimum 80%, and aim to keep specificity above 70%. Optimal threshold for the hospital population will maximise specificity, minimum 80%, and aim to keep sensitivity above 70%. Discussion The results from this study will determine how accurately the SMARTChip purine assay test can identify stroke mimic conditions within the suspected stroke population. If acceptable performance is confirmed, deployment of the test in ambulances or emergency departments could enable more appropriate direction of patients to stroke or non-stroke services. Trial registration Registered with ISRCTN (identifier: ISRCTN22323981) on 13/02/2019 http://www.isrctn.com/ISRCTN22323981

scholarly journals Changes in Prehospital Stroke Care and Stroke Mimic Patterns during the COVID-19 Lockdown

2021 ◽  
Vol 18 (4) ◽  
pp. 2150
Author(s):  
Kazimieras Melaika ◽  
Lukas Sveikata ◽  
Adam Wiśniewski ◽  
Altynshash Jaxybayeva ◽  
Aleksandra Ekkert ◽  
...  
Keyword(s):  
Stroke Care ◽  
Prospective Data ◽  
Hospital Arrival ◽  
Public Health Emergencies ◽  
Stroke Mimics ◽  
Care Patterns ◽  
Suspected Stroke ◽  
Stroke Mimic ◽  
The Impact ◽  
Stroke Centre

The impact of COVID-19 lockdown on prehospital stroke care is largely unknown. We aimed to compare stroke care patterns before and during a state-wide lockdown. Thus, we analysed prospective data of stroke alerts referred to our stroke centre between 1 December 2019 and 16 June 2020, and compared them between two periods—15 weeks before and 13 weeks during the state-wide lockdown declared in Lithuania on 16 March 2020. Among 719 referrals for suspected stroke, there was a decrease in stroke alerts (rate ratio 0.61, 95% CI (0.52–0.71)), stroke admissions (0.63, 95% CI (0.52–0.76)), and decrease in prehospital stroke triage quality (positive predictive value 72.1% vs. 79.9%, p = 0.042) during the lockdown. The onset-to-door time was longer (153.0 vs. 120.5 min, p = 0.049) and seizures and intracranial tumours were more common among stroke mimics (16.9% vs. 6.7%, p = 0.012 and 9.6% vs. 3.0%, p = 0.037, respectively). We conclude that there was a decline in prehospital stroke triage quality during the lockdown despite low COVID-19 incidence in the country. Moreover, we observed an increase in hospital arrival delays and severe conditions presenting as stroke mimics. Our findings suggest that improved strategies are required to maintain optimal neurological care during public health emergencies.

Abstract WP71: Intravenous Thrombolysis in Stroke-mimics: Is There a Relationship With Door-to-needle Time?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Elisa Campos-Costa ◽  
Carmen Labandeira-Guerra ◽  
Cristina Martínez-Reglero ◽  
Sandra Boned ◽  
Maria Muchada ◽  
...  
Keyword(s):  
Clinical Characteristics ◽  
Ct Perfusion ◽  
Intravenous Thrombolysis ◽  
Treatment Decision ◽  
Final Diagnosis ◽  
Neurological Deficits ◽  
Stroke Patients ◽  
Stroke Mimics ◽  
Contrast Ct ◽  
Iv Tpa

Introduction: Several non-vascular conditions may mimic the sudden neurological deficits of stroke (stroke mimics, SM). In Stroke Code, time to treatment is crucial, but the efforts to increase the benefits of iv-tPA may lead to inadvertent treatment of SM. We aim to determine the relationship between door-to-needle (DTN) time and SM treatment. Methods: Retrospective analysis of all acute stroke patients treated with iv-tPA included in an institutional prospective database. SM were identified during follow-up and their clinical characteristics compared with the confirmed stroke patients in the same time-period. Results: During a 3-year period, 332 thrombolysed patients were included. Twenty-two were SM (6.6%, 95%CI:4.0%-9.3%), with median age of 58 years (range 35-87), 54.5% were men, median NIHSS=10 (range 3-30). Sudden (81.8%) neurological deficits were motor in 11 patients (52.2%), altered speech in 10 (47.6%) and sensitive in 7 (33.3%). Baseline clinical characteristics (including age, sex, vascular risk factors and initial NIHSS) were similar between stroke and SM groups. Multimodal imaging was used for treatment decision in 95.5% of SM (CT-perfusion 10 patients, CT-angiography 9, MRI 1 and only 1 patient received just non-contrast CT) vs 74.1% of confirmed strokes (p=0.014). Four SM patients presented with neuroimaging abnormalities. DTN of SM was similar to those of strokes (35.5 VS. 40minutes, p=0.6). Despite a progressive decrease in median DTN time (year 1: 47min vs year 3: 36min; p=0.02) the rate of SM treated with tPA did not increase (year 1: 5.4% vs 9% in year 3; p=0.1). No intracranial haemorrhage or other complications were recorded in any SM patient. At discharge, 86.4% of SM presented a modified Rankin Scale 0-1. The most frequent final diagnosis were: migraine (31.8%), functional symptoms (27.3%) and seizures (27.3%). Conclusions: Despite multimodal neuroimaging, stat differentiation between SM and stroke is still difficult. Reduction of DTN times may not necessarily increase the number of SM thrombolysed. Nevertheless, iv-tPA revealed to be safe in SM and should not be delayed in case of doubt.

scholarly journals Prevalence and Risk Factors of Stroke in Bangladesh: A Nationwide Population-Based Survey

2021 ◽  
Author(s):  
Md Badrul Alam Mondal ◽  
A T M Hasibul Hasan ◽  
Nushrat Khan ◽  
Quazi Deen Mohammad
Keyword(s):  
Risk Factors ◽  
Heart Disease ◽  
Ischemic Heart Disease ◽  
Population Based ◽  
Ischemic Heart ◽  
List Type ◽  
Stroke Patients ◽  
Stroke Prevalence ◽  
Common Risk Factors ◽  
Suspected Stroke

AbstractBackgroundThis community survey was conducted to estimate the prevalence of stroke and its associated common risk factors among the Bangladeshi population.MethodsThis was a population-based cross-sectional study, carried out in 8 administrative divisions and 64 districts to estimate the prevalence of stroke throughout the country. The study adopted a two-stage cluster random sampling approach. The calculated sample size was 25,287. A semi-structured questionnaire was used to identify suspected stroke patients who were subsequently confirmed by consultant neurologists.ResultIn the first stage, Interviewers identified 561 respondents as suspected stroke in 64 districts. Of the 25,287 respondents, 54.9% were male. The mean age was 39.9 years. In the second stage of the study; among all the respondents, 288 were confirmed as stroke patients which provided a prevalence of 11.39 per 1000 population. The highest stroke prevalence (14.71 per thousand) was found in the Mymensingh division and the lowest (7.62 per thousand) found in the Rajshahi division. It was 30.10 per thousand in the age group of more than 60 years. The prevalence of stroke among males was twice that of females (13.62 versus 8.68 per thousand). The prevalence was slightly higher in rural areas (11.85 versus 11.07). Out of a total of 288 cases, 79.7% (213) patients had an ischemic stroke, 15.7% (42) had hemorrhagic, and 4.6% (12) were diagnosed as subarachnoid hemorrhage. The majority of the stroke patients had hypertension (79.2%), followed by dyslipidemia (38.9%), tobacco use in any form (37.2%), diabetes (28.8%), ischemic heart disease (20.1%).ConclusionWe have found a stroke prevalence of 11.39 per 1000 population, the highest being in the Mymensingh division. The prevalence was much higher in the elderly and male population. More than three fourth had an ischemic stroke. Hypertension, dyslipidemia, tobacco use, diabetes, ischemic heart disease are the most common risk factors observed among stroke patients.Summary BoxAlready Known:▪The prevalence of stroke in Bangladesh was found to be 3 per thousand.▪Hypertension, diabetes, dyslipidemia, smoking, and ischemic heart disease were common risk factors.New Findings:▪This is the first-ever nationwide survey in Bangladesh that revealed a stroke prevalence of 11.39 per thousand.▪There was a wide regional variation of stroke prevalence.▪The prevalence was twice among males.Impact of the study result:▪The study result will help the policymakers in deciding what to do for which regions of this country to handle the stroke burden.▪It will also help the clinicians to identify common risk factors among stroke patients.

Method of virtual reality for early comprehensive rehabilitation of patients with acute stroke

2020 ◽  
pp. 39-45
Author(s):  
N. Nozdryukhina ◽  
E. Kabayeva ◽  
E. Kirilyuk ◽  
K. Tushova ◽  
A. Karimov
Keyword(s):  
Virtual Reality ◽  
Literature Review ◽  
Acute Stroke ◽  
Functional Outcome ◽  
Recovery Process ◽  
Stroke Patients ◽  
Post Stroke ◽  
Stroke Disability ◽  
Comprehensive Rehabilitation ◽  
High Level

Despite significant advances in the treatment and rehabilitation of stroke, level of post-stroke disability remains at a fairly high level. Recent innovative developments in the rehabilitation of these patients provide good results in terms of functional outcome. One of such developments is method of virtual reality (VR), which affects not only the speed and volume of regaining movement, as well as coordination, but also normalizes the psycho-emotional background, increasing the motivation of patients to improve the recovery process. This article provides a literature review of the use of the VR method in the rehabilitation of post-stroke patients, neurophysiological aspects of recovery of lost functions using this method are considered.

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