Identification of Stroke Mimics in the Emergency Department Setting

Background and Purpose Previous studies have shown a stroke mimic rate of 9%–31%. We aimed to establish the proportion of stroke mimics amongst suspected acute strokes, to clarify the aetiology of stroke mimic and to develop a prediction model to identify stroke mimics. Methods This was a retrospective cohort observational study. Consecutive “stroke alert” patients were identified over nine months in a primary stroke centre. 31 variables were collected. Final diagnosis was defined as “stroke” or “stroke mimic”. Multivariable regression analysis was used to define clinical predictors of stroke mimic. Results 206 patients were reviewed. 22% were classified as stroke mimics. Multivariable scoring did not help in identification of stroke mimics. 99.5% of patients had a neurological diagnosis at final diagnosis. Discussion 22% of patients with suspected acute stroke had a stroke mimic. The aetiology of stroke mimics was varied, with seizure, encephalopathy, syncope and migraine being commonest. Multivariable scoring for identification of stroke mimics is not feasible. 99.5% of patients had a neurological diagnosis. This strengthens the case for the involvement of stroke neurologists/stroke physicians in acute stroke care.

Download Full-text

The impact of tele-neurologists on acute stroke care at an advanced primary stroke centre

Journal of Telemedicine and Telecare ◽

10.1177/1357633x20921039 ◽

2020 ◽

pp. 1357633X2092103

Author(s):

Scott Gutovitz ◽

Jonathan Leggett ◽

Leslie Hart ◽

Samuel M Leaman ◽

Heather James ◽

...

Keyword(s):

Acute Stroke ◽

Mechanical Thrombectomy ◽

Stroke Care ◽

Final Diagnosis ◽

Stroke Patients ◽

Acute Stroke Care ◽

Care Guidelines ◽

Stroke Center ◽

The Impact ◽

Stroke Centre

Introduction We evaluated the impact of tele-neurologists on the time to initiating acute stroke care versus traditional bedside neurologists at an advanced stroke center. Methods This observational study evaluated time to treatment for acute stroke patients at a single hospital, certified as an advanced primary stroke centre, with thrombectomy capabilities. Consecutive stroke alert patients between 1 March, 2016 and 31 March, 2018 were divided into two groups based on their neurology consultation service (bedside neurology: 1 March, 2016–28 February, 2017; tele-neurology: 1 April, 2017–31 March, 2018). Door-to-tPA time and door-to-IR time for mechanical thrombectomy were compared between the two groups. Results Nine hundred and fifty-nine stroke patients met the inclusion criteria (436 bedside neurology, 523 tele-neurology patients). There were no significant differences in sex, age, or stroke final diagnosis between groups ( p > 0.05). 85 bedside neurology patients received tPA and 35 had mechanical thrombectomy, 84 and 44 for the tele-neurology group respectively. Door-to-tPA time (median (IQR)) was significantly higher among tele-neurology (64 min (51.5–83.5)) than bedside neurology patients (45 min (34–69); p < 0.0001). There was no difference in door-to-IR times (mean ± SD) between bedside neurology (87.2 ± 33.3 min) and tele-neurology (90.4 ± 33.4 min; p = 0.67). Discussion At this facility, our tele-neurology services vendor was associated with a statistically significant delay in tPA administration compared with bedside neurologists. There was no difference in door-to-IR times. Delays in tPA administration make it harder to meet acute stroke care guidelines and could worsen patient outcomes.

Download Full-text

Abstract WMP68: Smartphone Support System for Mobile Imaging Display and Management of Acute Stroke

Stroke ◽

10.1161/str.47.suppl_1.wmp68 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Kristina Shkirkova ◽

Eftitan Y Akam ◽

Josephine F Huang ◽

Sunil A Sheth ◽

May Nour ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Final Diagnosis ◽

Integrated System ◽

Ease Of Use ◽

Imaging Data ◽

Acute Stroke Care ◽

Team Members ◽

Information Platform ◽

Stroke Team

Introduction: Rapid dissemination and coordination of clinical and imaging data among multidisciplinary team members is essential for optimal acute stroke care. Standard desktop EMRs are ill-suited for this purpose, but mobile smartphone and tablet applications are highly promising platforms for accelerated, data-driven patient diagnosis and treatment. This study tested an advanced mobile integrated system for distribution of patient clinical and imaging information. Methods: We tested the iStroke/Synapse ERm system (Figure) for smartphone and tablet display and integration of clinical data, CT, MR, and catheter angiographic imaging, and real-time stroke team communications, in consecutive acute neurovascular patients at a Comprehensive Stroke Center. Results: From 5/2014 to 10/2014, the Synapse ERm application was installed and used by 33 stroke team members, in 84 Code Stroke ED patients. Patient age was 69.1 (±17.5), with 40.5% female. Final diagnosis was: ischemic stroke 66%, TIA 7%, ICH 6%, and CV mimic 21%. Each patient record was viewed on average 13 times by at least 3 team members. The most used feature was CT, MR and cath angio image display, viewed on average 4 times per patient by at least 2 users. In-app tweet team communications were sent by average 2 users per case and viewed by average 6 team members. Use of the system was associated with treatment times that exceeded national guideline targets for thrombolysis and endovascular thrombectomy, including door-to-needle 50 min (IQR 24-60) and door-to-groin 92 min (IQR 65-128). In user surveys, the mobile information platform was judged easy to employ in 91% of uses and of added help in stroke management in a substantial majority of cases. Conclusion: The Synapse ERm system, a smartphone/tablet platform for stroke team communication and distribution and integration of clinical and imaging data, showed high ease of use, substantial added management value, and association with rapid processes of care.

Download Full-text

Migraine with Aura as a Stroke Mimic

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2019.316 ◽

2019 ◽

Vol 47 (2) ◽

pp. 242-244

Author(s):

Jeong-Jin Park ◽

Soo Jeong Kim ◽

Hahn Young Kim ◽

Hong Gee Roh ◽

Dong Wook Kim

Keyword(s):

Atrial Fibrillation ◽

Acute Stroke ◽

Migraine Attack ◽

Migraine With Aura ◽

Medical Records ◽

Final Diagnosis ◽

Stroke Management ◽

Stroke Mimics ◽

Management Protocol ◽

Stroke Mimic

ABSTRACT:Migraine with aura is one of the causes of stroke mimics. We retrospectively reviewed the 10-year medical records of patients who were treated with acute stroke management protocol. We analyzed the frequency and characteristics of patients with a final diagnosis of migraine with aura. Among the 1355 patients with stroke mimics, migraine with aura was the final diagnosis in 36 patients (2.7%). The most common auras included sensory and brainstem auras followed by motor, visual, and speech/language auras. One patient manifested transient atrial fibrillation during the migraine attack, which can be a link with acute stroke.

Download Full-text

Abstract TP259: Accuracy of EMS Identification of Acute Strokes Eligible for tPA Treatment in Kaiser Stroke EXPRESS Program

Stroke ◽

10.1161/str.48.suppl_1.tp259 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jeffrey G Klingman ◽

Sunil Bhopale ◽

Meghan Hatfield ◽

Benjamin Wilson ◽

Lauren Klingman ◽

...

Keyword(s):

Acute Stroke ◽

Stroke Care ◽

Work Flow ◽

Initial Assessment ◽

Stroke Therapy ◽

Acute Stroke Care ◽

Kaiser Permanente ◽

Vessel Occlusion ◽

Stroke Mimic

Background: Field-based diversion for potential stroke patients who may qualify for endovascular stroke therapy (EST) has been proposed more widely in 2015. In 2015, Kaiser Permanente Northern California (KPNC) redesigned its acute stroke care work flow for all its 21 stroke centers, which included rapid evaluation of all stroke alerts by a stroke neurologist via teleneurology. We investigated the accuracy of EMS-activated stroke alerts. Methods: From 1/1/16 to 7/10/16, all acute strokes presenting to an ED between 7 AM and midnight were assessed upon arrival by a teleneurologist. We reviewed all telestroke cases to determine the frequency of tPA given, cancelled stroke alerts, and the reasons for not treating with IV t-PA, particularly among ambulance arrivals. Multivariate logistic regression was used to assess age, gender, race, Kaiser membership, and mode of ED arrival as predictors of stroke alert cancellation. Results: There were 2192 stroke alerts activated. Of these, 1332 (60.7%) arrived by EMS and 860 (39.2%) by non-EMS transport. Of patients arriving by EMS, 651 (48.9%) were cancelled and deemed ineligible for IV t-PA. Most common reasons for cancellation were: last time known well (LTKW) out of range (23%), stroke mimic (33%), symptom resolution (19%), new data regarding goals of care (2%), and other (22.5%). The remaining 681 (51.1%) ambulance arrivals were potential candidates for IV tPA. Subsequently, 334 (50.4%) of them received tPA. Reasons for tPA not given included subsequent resolution of symptoms, concerning CT findings (such as bleed), INR>1.7 in patients on warfarin, further information clarifying time of onset. Among those who arrived by EMS and received IV t-PA, all had CTA and 103 (30.8%) were found to have a large vessel occlusion and 74 (71.8%) underwent EST. In multivariate analysis for all cancelled stroke alerts, arrival by non-EMS transport (OR=1.74, 95% CI 1.44-2.10, p<0.001) was more likely to be cancelled. Conclusions: Close to half of EMS-activated stroke alerts were cancelled upon initial assessment. Only 5% of patients initially identified by EMS as having a potential acute stroke ultimately underwent EST. Better determination of LTKW and stroke symptoms would improve the accuracy of EMS-initiated stroke alerts.

Download Full-text

Optimal patient protocols in regional acute stroke care

Health Care Management Science ◽

10.1007/s10729-020-09524-2 ◽

2021 ◽

Author(s):

B. L. Garcia ◽

R. Bekker ◽

R. D. van der Mei ◽

N. H. Chavannes ◽

N. D. Kruyt

Keyword(s):

Acute Stroke ◽

Rural Areas ◽

Interventional Procedure ◽

Treated Patient ◽

Stroke Care ◽

Mixed Integer ◽

Acute Stroke Care ◽

Mixed Integer Linear Program ◽

Patient Allocation ◽

Stroke Centre

AbstractIn acute stroke care two proven reperfusion treatments exist: (1) a blood thinner and (2) an interventional procedure. The interventional procedure can only be given in a stroke centre with specialized facilities. Rapid initiation of either is key to improving the functional outcome (often emphasized by the common phrase in acute stroke care “time=brain”). Delays between the moment the ambulance is called and the initiation of one or both reperfusion treatment(s) should therefore be as short as possible. The speed of the process strongly depends on five factors: patient location, regional patient allocation by emergency medical services (EMS), travel times of EMS, treatment locations, and in-hospital delays. Regional patient allocation by EMS and treatment locations are sub-optimally configured in daily practice. Our aim is to construct a mathematical model for the joint decision of treatment locations and allocation of acute stroke patients in a region, such that the time until treatment is minimized. We describe acute stroke care as a multi-flow two-level hierarchical facility location problem and the model is formulated as a mixed integer linear program. The objective of the model is the minimization of the total time until treatment in a region and it incorporates volume-dependent in-hospital delays. The resulting model is used to gain insight in the performance of practically oriented patient allocation protocols, used by EMS. We observe that the protocol of directly driving to the nearest stroke centre with special facilities (i.e., the mothership protocol) performs closest to optimal, with an average total time delay that is 3.9% above optimal. Driving to the nearest regional stroke centre (i.e., the drip-and-ship protocol) is on average 8.6% worse than optimal. However, drip-and-ship performs better than the mothership protocol in rural areas and when a small fraction of the population (at most 30%) requires the second procedure, assuming sufficient patient volumes per stroke centre. In the experiments, the time until treatment using the optimal model is reduced by at most 18.9 minutes per treated patient. In economical terms, assuming 150 interventional procedures per year, the value of medical intervention in acute stroke can be improved upon up to € 1,800,000 per year.

Download Full-text

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

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18042150 ◽

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.

Download Full-text

CT perfusion: stroke, seizure or both?

BMJ Case Reports ◽

10.1136/bcr-2021-245723 ◽

2021 ◽

Vol 14 (12) ◽

pp. e245723

Author(s):

Elizebath Davies ◽

Fathalla Elnagi ◽

Thomas Smith

Keyword(s):

Acute Stroke ◽

Small Vessel Disease ◽

Ct Perfusion ◽

Stroke Care ◽

Large Vessel ◽

Arterial Calcification ◽

Acute Stroke Care ◽

Vessel Occlusion ◽

History Of ◽

Stroke Mimic

An 88-year-old male with a history of hypertension, ischaemic heart disease and Bell’s palsy presented with symptoms and signs of an acute ischaemic stroke. National Institutes of Health Stroke Scale (NIHSS) was 19 at presentation, indicative of potential large vessel occlusion. The initial CT scan revealed evidence of small vessel disease and arterial calcification. As there were no contraindications, he received thrombolytic treatment. CT angiography and CT perfusion imaging were performed in preparation for possible thrombectomy. There was no evidence of a large vessel thrombus, and changes on CT perfusion were suggestive of seizure activity, with relative hyperperfusion on the cerebral hemisphere of interest. Post thrombolysis, his NIHSS was 5. An MR scan revealed evidence of bilateral thalamic infarcts. After a period of rehabilitation, he was discharged home and independently mobile but with cognitive impairment.Acute stroke care increasingly uses multimodal imaging to confirm the clinical diagnosis and help optimise initial emergency management. Such imaging is useful in determining whether the presentation is a vascular event or stroke mimic. Moreover, seizures complicate and mimic acute strokes, which can lead to therapeutic uncertainty. This case highlights the increasingly sophisticated investigation of patients presenting with suspected acute stroke, with the attendant need for accurate interpretation by experienced clinicians.

Download Full-text