scholarly journals Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes

Neurology ◽  
2017 ◽  
Vol 89 (4) ◽  
pp. 343-348 ◽  
Author(s):  
Tina M. Burton ◽  
Marie Luby ◽  
Zurab Nadareishvili ◽  
Richard T. Benson ◽  
John K. Lynch ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Hemorrhagic Transformation ◽  
Discharge Disposition ◽  
Stroke Mimics ◽  
Stroke Diagnosis ◽  
Tissue Plasminogen ◽  
Hospital Patients ◽  
Stroke Mimic

Objective:To determine to what degree stroke mimics skew clinical outcomes and the potential effects of incorrect stroke diagnosis.Methods:This retrospective analysis of data from 2005 to 2014 included IV tissue plasminogen activator (tPA)–treated adults with clinical suspicion for acute ischemic stroke who were transferred or admitted directly to our 2 hub hospitals. Primary outcome measures compared CT-based spoke hospitals' and MRI-based hub hospitals' mimic rates, hemorrhagic transformation, follow-up modified Rankin Scale (mRS), and discharge disposition. Secondary outcomes were compared over time.Results:Of the 725 thrombolysis-treated patients, 29% were at spoke hospitals and 71% at hubs. Spoke hospital patients differed from hubs by age (mean 62 ± 15 vs 72 ± 15 years, p < 0.0001), risk factors (atrial fibrillation, 17% vs 32%, p < 0.0001; alcohol consumption, 9% vs 4%, p = 0.007; smoking, 23% vs 13%, p = 0.001), and mimics (16% vs 0.6%, p < 0.0001). Inclusion of mimics resulted in better outcomes for spokes vs hubs by mRS ≤1 (40% vs 27%, p = 0.002), parenchymal hematoma type 2 (3% vs 7%, p = 0.037), and discharge home (47% vs 37%, p = 0.01). Excluding mimics, there were no significant differences. Comparing epochs, spoke stroke mimic rate doubled (9%–20%, p = 0.03); hub rate was unchanged (0%–1%, p = 0.175).Conclusions:Thrombolysis of stroke mimics is increasing at our CT-based spoke hospitals and not at our MRI-based hub hospitals. Caution should be used in interpreting clinical outcomes based on large stroke databases when stroke diagnosis at discharge is unclear. Inadvertent reporting of treated stroke mimics as strokes will artificially elevate overall favorable clinical outcomes with additional downstream costs to patients and the health care system.

Abstract 14767: Thrombolysis of Stroke Mimics via Telestroke

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Ravyn Howell ◽  
Randheer S Yadav ◽  
Sushil Lakhani ◽  
Sharon Heaton ◽  
Karen L Wiles ◽  
...  
Keyword(s):  
Final Diagnosis ◽  
National Institutes Of Health ◽  
Factitious Disorder ◽  
Emergency Rooms ◽  
Stroke Mimics ◽  
Intravenous Tissue Plasminogen Activator ◽  
Stroke Diagnosis ◽  
History Of ◽  
Stroke Mimic ◽  
Similar Episode

Introduction: Telestroke allows stroke expertise for thrombolysis decision making remotely using high-quality bidirectional audiovisual technology. Hypothesis: Intravenous tissue plasminogen activator (IVtPA) is administered via telestroke network to a proportion of patients without a stroke diagnosis (i.e. stroke mimic) Methods: Our academic comprehensive stroke program telestroke program includes 26 spoke Emergency rooms (ERs) through which IVtPA is administered throughout central Ohio. From July 1, 2016 to Sept 30, 2017, nearly all patients who received IVtPA at the outside hospital telestroke ERs were transferred to our institution for post-IVtPA care. Data was collected on final diagnosis, demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle (DTN) time, and outcomes. Results: Among 270 acute ischemic stroke patients who received IVtPA via telestroke, we identified 64 (23.7%) with a stroke mimic diagnosis. Stroke mimics were younger (mean age 56.4 vs 68.2, p <0.0001), more likely female (60.9% vs 45.6%, p 0.03), and had higher DTN times (85.3 vs 69.9 minutes, p 0.0008). The increase in DTN was due to longer time to recommend by the telestroke neurologist for stroke mimic (65.0 vs 53.2 minutes, p 0.0034). The stroke mimic diagnosis included Migraine 26 (40.6%), Factitious disorder 12 (18.8%), Encephalopathy 7 (10.9%), and Unmasking 6 (9.4%). The stroke mimics did not differ from each other based upon initial NIHSS, DTN, or sex. Compared to the other stroke mimics, Migraine and Factitious disorder patients were younger (51.2 vs 63.9 years, p <0.0006), more likely to have a personal history of migraines (42.1% vs 0%, p < 0.0001), and more likely to have functional exam findings (42.1% vs 3.8%, p 0.0007). There were no hemorrhagic complications in the stroke mimic patients. Among all stroke mimics, 26 (40.6%) had a history of similar prior episodes and 10 (15.6%) would have future recurrence of another similar episode, with 2 patients receiving IVtPA again in the future (1 Migraine and 1 Factitious disorder). Conclusions: In a tertiary academic telestroke network, nearly one-quarter of patients receive IVtPA for a non-stroke diagnosis, with migraine and factitious disorder being the most commonly seen.

Abstract P274: Kidney Filtration Markers and the Risk of Clinical Outcomes in Individuals With Type 2 Diabetes in the Advance Trial

Circulation ◽  
2020 ◽  
Vol 141 (Suppl_1) ◽  
Author(s):  
Hyunju Kim ◽  
Dan Wang ◽  
John Chalmers ◽  
Mark Woodward ◽  
Elizabeth Selvin ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Clinical Outcomes ◽  
Regression Models ◽  
Cox Regression ◽  
All Cause Mortality ◽  
Baseline Levels ◽  
Controlled Evaluation ◽  
Egfr Decline

Introduction: Creatinine-based estimated glomerular filtration rate (eGFR) is biased in the setting of obesity and other conditions. Alternative kidney filtration markers may be particularly useful in adults with diabetes, but few studies examined the risk of clinical outcomes associated with filtration markers in adults with type 2 diabetes. Objective: We evaluated whether baseline levels and change in eGFR based on creatinine (Cr), cystatin C (Cys), and B 2 -microglobulin (B2M) were associated with the risk of clinical outcomes among individuals with type 2 diabetes. Methods: In the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial, Cr, Cys, and B2M were measured in 7,217 participants at baseline and a random sample of 640 participants at the 1 year visit. We categorized baseline eGFR Cr , eGFR Cys , eGFR B2M , and the average across the 3 eGFR estimates (eGFR avg ) into quarters, and examined associations with major macrovascular and microvascular events together, and separately, and all-cause mortality using Cox regression models, adjusting for established risk factors. We also examined associations with continuous eGFR decline and increase (per 30%). Results: Over a median follow-up of 5 years, 1,313 combined major macrovascular (n=748) and microvascular events (n=637), and 743 deaths occurred. Lower levels of eGFR based on all three filtration markers individually and combined were associated with 1.5 to 2.2 times higher risk of combined major macrovascular and microvascular events, with similar patterns for other outcomes ( Table ). Per 30% decline in eGFR Cys and eGFR avg were associated with a >2-fold higher risk of all clinical outcomes, after additional adjustment of baseline eGFR. Conclusions: In adults with type 2 diabetes, baseline levels of eGFR based on alternative filtration markers and per 30% decline in eGFR Cys and eGFR avg were consistently associated with all clinical outcomes.

Telestroke consultation can accurately diagnose ischemic stroke mimics

2021 ◽  
pp. 1357633X2198955
Author(s):  
Jason T Poon ◽  
Aleksander Tkach ◽  
Adam H de Havenon ◽  
Knut Hoversten ◽  
Jaleen Johnson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Predictive Value ◽  
Clinical Information ◽  
Excellent Correlation ◽  
Stroke Mimics ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Us ◽  
Tissue Plasminogen ◽  
Stroke Mimic ◽  
Ischemic Attack

Introduction Telestroke (TS) networks are standard in many areas of the US. Despite TS systems having approximately 33% mimic rates, it is unknown if TS can accurately diagnose patients with acute ischemic stroke (AIS) versus stroke mimics. Methods We performed a retrospective review of consecutive TS consults to 27 TS sites in six states during 2018. Clinical information and diagnosis were extracted from discharge records and compared to those from the TS consult. Discharge diagnoses were verified and coded into 12 categories. Cases without a clear discharge diagnosis and intracerebral haemorrhage were excluded. We report agreement and a Cohen’s kappa between TS and discharge diagnoses for the category of AIS/transient ischemic attack (TIA) versus stroke mimic. Results We included 404 cases in the analysis (mean age 66 years; 54% women). Of these, 225 had a TS diagnosis of AIS/TIA; 102 (45%) received intravenous tissue plasminogen activator. Our study demonstrated a high diagnostic agreement for AIS/TIA (88%) with a kappa of 0.75 for stroke and mimics. Of the 179 patients diagnosed with a stroke mimic on TS, 27 (15%) were diagnosed with AIS/TA by discharge. TS mimic diagnosis had a positive predictive value (PPV) of 85% and a negative predictive value (NPV) of 90%; TS diagnosis of stroke/TIA had PPV 90%, NPV 85%. Discussion We found excellent correlation between TS and discharge diagnoses for patients with both stroke and stroke mimics. This suggests that TS systems can accurately assess a wider variety of patients with acute neurologic syndromes other than AIS.

scholarly journals Intravenous Thrombolysis for a Stroke Mimic Patient

2021 ◽  
pp. 704-709
Author(s):  
Lilly Nguyen ◽  
Joyce Hoonsuh Lee ◽  
Latha Ganti ◽  
Mark Rivera-Morales ◽  
Larissa Dub
Keyword(s):  
Cerebrovascular Disease ◽  
Acute Stroke ◽  
Plasminogen Activator ◽  
Young Woman ◽  
Intravenous Thrombolysis ◽  
Herbal Supplements ◽  
Stroke Mimics ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Stroke Mimic

The authors present the case of a young woman on phentermine and herbal supplements who presented as an acute stroke alert with right-sided facial droop and numbness. She was treated acutely with intravenous tissue plasminogen activator (tPA). However, the workup did not reveal any evidence of cerebrovascular disease or cerebral infarct. The authors discuss plausible stroke mimics and the safety of administering tPA to such patients.

scholarly journals Comparison of clinical outcomes of sitagliptin+metformin combination and glimepiride in the management of uncomplicated type 2 diabetics

2018 ◽  
Vol 8 (1) ◽  
pp. 16
Author(s):  
Jarinabanu Tahashildar ◽  
Ravi Shekhar Singh ◽  
Jameela Tahashildar
Keyword(s):  
Adverse Events ◽  
Clinical Outcomes ◽  
Diabetic Patients ◽  
Open Label ◽  
Type 2 Diabetics ◽  
Significant Difference ◽  
Group A ◽  
Group B

Background: To evaluate the comparison of clinical outcomes of sitagliptin +metformin and glimepride in uncomplicated Type-2 diabetics.Methods: This one year (July 2016 to August 2017) prospective, open label, observational clinical cohort study was carried out on type-2 diabetics. In this study 299 Type-2 diabetics patients were enrolled and were randomly allocated to two groups viz Group A and Group B. Group A received sitaglitin+metformin (50+500) mg/day and Group B received glimepride 1mg/day respectively. The follow up started after 10 days of stabilization of the patient and data recorded on 10th day was considered Zero month data and follow up continued up to Six month in each group. Comparison of FPG, PPG and HbA1c was evaluated between zero and six months within group and at six month between groups. Adverse events were recorded and summarized by treatment group.Results: At the end of six months follow up the patients of Group A who received sitaglitin+metformin (50+500) mg/day had greater reduction in FPG, PPG and HbA1c (all P<0.001) was recorded when compared between zero and six month within group. A significant reduction in FPG, PPG and HbA1c (all P<0.01) also recorded in Group B who received glimepride 1mg/day when compared between zero and six months within group. A statically significant difference (all P<0.05) was recorded at six months between group. The adverse events like hypoglycemic episodes, gastrointestinal adverse events etc were greater in Group B than Group A. Changes in weight also noted in both Groups. Weight loss in Group A and weight gain in Group B was recorded.Conclusions: The present study suggests that a significant difference may be existing in the clinical outcome interm of glycemia control and adverse events between sitagliptin+metformin combination and glimepride in type-2 diabetic patients.

Hyperglycemic hemianopia as a stroke mimic in hyperosmolar non ketotic state in type 2 Diabetes

1970 ◽  
Vol 1 (1) ◽  
pp. 7-9
Author(s):  
Sumesh Raj ◽  
Manoj Parameswaran ◽  
Jijun M Ignatius
Keyword(s):  
Multiple Sclerosis ◽  
Type 2 Diabetes ◽  
Metabolic Disorders ◽  
Central Nervous System Involvement ◽  
Neurological Deficits ◽  
Stroke Mimics ◽  
Complicated Migraine ◽  
Psychiatric Conditions ◽  
Stroke Mimic

Stroke mimics are differential presentations of various systemic disorders that simulate an acute stroke. The conditions vary from numerous metabolic and psychiatric conditions to central nervous system involvement in the form of cerebral tumours, complicated migraine, myasthenia gravis and multiple sclerosis. Metabolic disorders represent a small mimicking subgroup of acute focal neurological deficits. They include hypoglycemia, hyperglycemia, hyponatremia, hypoxia, uremia encephalopathy and hepatic encephalopathy. Here we report a case of transient homonymous hemianopia and seizures in a patient with hyperosmolar non ketotic state which got completely reversed as euglycemia was achieved.

scholarly journals To tPA or Not to tPA: Two Medical-Legal Misadventures of Diagnosing a Cerebrovascular Accident as a Stroke Mimic

2019 ◽  
Vol 3 (3) ◽  
pp. 194-198
Author(s):  
Malia Moore ◽  
Jonathan Stuart ◽  
Alexandra Humphreys ◽  
James Pfaff
Keyword(s):  
Plasminogen Activator ◽  
Cerebrovascular Accident ◽  
Conversion Disorder ◽  
Family Interactions ◽  
Hemiplegic Migraine ◽  
Cerebrovascular Accidents ◽  
Stroke Mimics ◽  
Poor Patient ◽  
Tissue Plasminogen ◽  
Stroke Mimic

We present two recent successfully litigated malpractice cases in which patients with cerebrovascular accidents were misdiagnosed as stroke mimics. The first was diagnosed as a hemiplegic migraine, which occurs in only 0.01% of the population. The second was diagnosed as a conversion disorder, which ultimately has a neurologic etiology in 4% of cases. In both cases, issues of poor patient communication and poor documentation were paramount in the legal outcome. We discuss caveats of stroke mimics, tissue plasminogen activator administration liability, and pitfalls in patient and family interactions.

scholarly journals Implementation of a Personalized Care Plan for Patients With Type 2 Diabetes Is Associated With Improvements in Clinical Outcomes: An Observational Real-World Study

2020 ◽  
Vol 11 ◽  
pp. 215013272092170
Author(s):  
Anni Vuohijoki ◽  
Ilona Mikkola ◽  
Jari Jokelainen ◽  
Sirkka Keinänen-Kiukaanniemi ◽  
Klas Winell ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Type 2 Diabetes ◽  
Health Care ◽  
Clinical Outcomes ◽  
Real World ◽  
Care Plan ◽  
Personalized Care ◽  
Primary Health

Objective: To analyze the clinical outcomes of patients with type 2 diabetes (T2D) before and after implementation of a personalized care plan in the primary health care setting. Design: Observational, retrospective, real-world study. Setting: All T2D patients with a care plan in Rovaniemi Health Center, Rovaniemi, Finland, for whom data were available from a baseline visit (in 2013-2015 during which the care plan was written) and from a follow-up visit, including an updated care plan by the year 2017. Subjects: In total, 447 patients were included. Mean age was 66.9 (SD 10.1) years, 58.8% were male, 15.4% were smokers, 33.1% had vascular disease, and 17.0% were receiving insulin treatment. The mean follow-up time was 14.4 months. Main Outcome Measures: Glycosylated hemoglobin A1 (HbA1c), low-density lipoprotein (LDL), blood pressure (BP), and body mass index (BMI). Clinical values were taken at both baseline and follow-up. Results: LDL decreased by 0.2 mmol/L, systolic blood pressure by 2.2 mm Hg, diastolic blood pressure by 1.5 mm Hg, and BMI by 0.5 kg/m2 ( P < .05 for each). The decrease in HbA1c was 0.8 mmol/mol ( P = .07). Conclusion: We observed statistically significant decreases in LDL, BP, and BMI. Our results indicate that, over 14 months of follow-up, implementation of a written care plan was associated with small improvements in the clinical outcomes of T2D patients in a primary health care study population in a real-world setting.

Hemorrhagic transformation is associated with poor functional outcome in patients with acute ischemic stroke due to a large vessel occlusion

2018 ◽  
Vol 11 (5) ◽  
pp. 464-468 ◽  
Author(s):  
Katinka R van Kranendonk ◽  
Kilian M Treurniet ◽  
Anna M M Boers ◽  
Olvert A Berkhemer ◽  
Lucie A van den Berg ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Hemorrhagic Transformation ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Hemorrhagic Infarction

Background and purposeHemorrhagic transformation (HT) is a complication that may cause neurological deterioration in patients with acute ischemic stroke. Various radiological subtypes of HT can be distinguished. Their influence on functional outcome is currently unclear. The purpose of this study was to assess the associations between HT subtypes and functional outcome in acute ischemic stroke patients with proven large vessel occlusion included in the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic stroke in The Netherlands).MethodsAll patients with follow-up imaging were included. HT was classified on follow-up CT scans according to the European Cooperative Acute Stroke Study II classification. Functional outcome was assessed using the modified Rankin Scale (mRS) 90 days after stroke onset. Ordinal logistic regression analysis with adjustment for potential confounders was used to determine the association of HT subtypes with functional outcome.ResultsOf 478 patients, 222 had HT. Of these, 76 (16%) patients were classified as hemorrhagic infarction type 1, 71 (15%) as hemorrhagic infarction type 2, 36 (8%) as parenchymal hematoma type 1, and 39 (8%) as parenchymal hematoma type 2. Hemorrhagic infarction type 2 (adjusted common OR (acOR) 0.54, 95% CI: 0.32 to 0.89) and parenchymal hematoma type 2 (acOR 0.37, 95% CI 0.17 to 0.78) were significantly associated with a worse functional outcome. Hemorrhagic infarction type 1 and parenchymal hematoma type 1 were not significantly associated, although their point estimates pointed in the direction of worse outcome.ConclusionThis study suggests that parenchymal hematoma type 2 is relevant for functional outcome after an acute ischemic stroke, and smaller HTs might also influence long term functional outcome.Trail registration numberISRCTN10888758.

Sign in / Sign up

Export Citation Format

Share Document