Journal of The Korean Society of Emergency Medicine (대한응급의학회지)

The Korean Society of Emergency Medicine (대한응급의학회)
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Clinical features and risk factors for missed stroke team activation in cases of acute ischemic stroke in the emergency department

  • Byun, Young-Hoon (Department of Emergency Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea) ;
  • Hong, Sung-Youp (Department of Emergency Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea) ;
  • Woo, Seon-Hee (Department of Emergency Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea) ;
  • Kim, Hyun-Jeong (Department of Radiology, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea) ;
  • Jeong, Si-Kyoung (Department of Emergency Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea)
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  • ;
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  • 정시경 (가톨릭대학교 대전성모병원 응급의학과)
  • Received : 2018.06.08
  • Accepted : 2018.08.15
  • Published : 2018.10.31

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Abstract

Objective: Acute ischemic stroke (AIS) requires time-dependent reperfusion therapy, and early recognition of AIS is important to patient outcomes. This study was conducted to identify the clinical features and risk factors of AIS patients that are missed during the early stages of diagnosis. Methods: We retrospectively reviewed AIS patients admitted to a hospital through the emergency department. AIS patients were defined as ischemic stroke patients who visited the emergency department within 6 hours of symptom onset. Patients were classified into two groups: an activation group (A group), in which patients were identified as AIS and the stroke team was activated, and a non-activation group (NA group), for whom the stroke team was not activated. Results: The stroke team was activated for 213 of a total of 262 AIS patients (81.3%), while it was not activated for the remaining 49 (18.7%). The NA group was found to be younger, have lower initial National Institutes of Health Stroke Scale scores, lower incidence of previous hypertension, and a greater incidence of cerebellum and cardio-embolic infarcts than the A group. The chief complaints in the A group were traditional stroke symptoms, side weakness (61.0%), and speech disturbance (17.8%), whereas the NA group had non-traditional symptoms, dizziness (32.7%), and decreased levels of consciousness (22.4%). Independent factors associated with missed stroke team activation were nystagmus, nausea/vomiting, dizziness, gait disturbance, and general weakness. Conclusion: A high index of AIS suspicion is required to identify such patients with these findings. Education on focused neurological examinations and the development of clinical decision tools that could differentiate non-stroke and stroke are needed.

Keywords

References

  1. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947. https://doi.org/10.1161/STR.0b013e318284056a
  2. Berge E, Langhorne P, Cochrane Stroke Group. Cochrane Stroke Group: twenty years of evidence-based stroke medicine. Int J Stroke 2014;9:107-9. https://doi.org/10.1111/ijs.12234
  3. Richoz B, Hugli O, Dami F, Carron PN, Faouzi M, Michel P. Acute stroke chameleons in a university hospital: risk factors, circumstances, and outcomes. Neurology 2015;85:505-11. https://doi.org/10.1212/WNL.0000000000001830
  4. Lever NM, Nystrom KV, Schindler JL, Halliday J, Wira C. 3rd, Funk M. Missed opportunities for recognition of ischemic stroke in the emergency department. J Emerg Nurs 2013;39:434-9. https://doi.org/10.1016/j.jen.2012.02.011
  5. Arch AE, Weisman DC, Coca S, Nystrom KV, Wira CR 3rd, Schindler JL. Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke 2016;47:668-73. https://doi.org/10.1161/STROKEAHA.115.010613
  6. Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large populationbased sample. Diagnosis (Berl) 2014;1:155-66. https://doi.org/10.1515/dx-2013-0038
  7. Kuruvilla A, Bhattacharya P, Rajamani K, Chaturvedi S. Factors associated with misdiagnosis of acute stroke in young adults. J Stroke Cerebrovasc Dis 2011;20:523-7. https://doi.org/10.1016/j.jstrokecerebrovasdis.2010.03.005
  8. von Sarnowski B, Schminke U, Grittner U, et al. Posterior versus anterior circulation stroke in young adults: a comparative study of stroke aetiologies and risk factors in stroke among young fabry patients (sifap1). Cerebrovasc Dis 2017;43:152-60. https://doi.org/10.1159/000454840
  9. Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 2006;37:2484-7. https://doi.org/10.1161/01.STR.0000240329.48263.0d
  10. Royl G, Ploner CJ, Leithner C. Dizziness in the emergency room: diagnoses and misdiagnoses. Eur Neurol 2011;66:256-63. https://doi.org/10.1159/000331046
  11. Newman-Toker DE, Hsieh YH, Camargo CA Jr, Pelletier AJ, Butchy GT, Edlow JA. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc 2008;83:765-75. https://doi.org/10.4065/83.7.765
  12. Lee H, Sohn SI, Cho YW, et al. Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns. Neurology 2006;67:1178-83. https://doi.org/10.1212/01.wnl.0000238500.02302.b4
  13. Plum F, Posner JB. The diagnosis of stupor and coma. Brain Nerve 2015;67:344-5.
  14. Dupre CM, Libman R, Dupre SI, Katz JM, Rybinnik I, Kwiatkowski T. Stroke chameleons. J Stroke Cerebrovasc Dis 2014;23:374-8. https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.07.015
  15. Benbadis SR, Sila CA, Cristea RL. Mental status changes and stroke. J Stroke Cerebrovasc Dis 1994;4:216-9. https://doi.org/10.1016/S1052-3057(10)80093-X
  16. Kumral E, Kisabay A, Atac C, Kaya C, Calli C. The mechanism of ischemic stroke in patients with dolichoectatic basilar artery. Eur J Neurol 2005;12:437-44. https://doi.org/10.1111/j.1468-1331.2005.00993.x
  17. Williams LS, Yilmaz EY, Lopez-Yunez AM. Retrospective assessment of initial stroke severity with the NIH Stroke Scale. Stroke 2000;31:858-62. https://doi.org/10.1161/01.STR.31.4.858
  18. Kasner SE, Chalela JA, Luciano JM, et al. Reliability and validity of estimating the NIH stroke scale score from medical records. Stroke 1999;30:1534-7. https://doi.org/10.1161/01.STR.30.8.1534