Morgenstern L B, Lisabeth L D, Mecozzi A C, Smith M A, Longwell P J, McFarling D A, Risser J M H
Stroke Program, University of Michigan Health System, and Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, USA.
Neurology. 2004 Mar 23;62(6):895-900. doi: 10.1212/01.wnl.0000115103.49326.5e.
Acute stroke therapy is heavily dependent on the diagnostic acumen of the physician in the emergency department (ED).
To determine this diagnostic accuracy in a population-based multiethnic stroke study.
The Brain Attack Surveillance in Corpus Christi (BASIC) Project prospectively ascertained all acute stroke or TIA cases in an urban Texas county of 313,645 residents without an academic medical center. Cases were validated by board-certified neurologists using source documentation. Case validation was used as the gold standard to compare the diagnosis given by the ED physician.
From January 2000 to August 2002, a total of 13,015 patients were screened. Of these, 1,800 were validated as stroke/TIA. Overall sensitivity of the emergency physician for the BASIC-validated diagnosis was 92%, and positive predictive value was 89%. Of the cases that the emergency physician thought were stroke, 11% were validated as no stroke. In multivariable modeling, motor symptoms was an independent predictor of protection from false-negative ED diagnosis of stroke/TIA (odds ratio [OR] = 0.61; 95% CI 0.41 to 0.89). Protection from false-positive stroke/TIA diagnosis was predicted by sensory symptoms (OR = 0.43; 95% CI 0.28 to 0.66), motor symptoms (OR = 0.44; 95% CI 0.32 to 0.62), and severe neurologic deficit (OR = 0.33; 95% CI 0.14 to 0.78). History of stroke/TIA predicted false-positive stroke diagnosis (OR = 1.72; 95% CI 1.23 to 2.40). The majority of disagreements occurred in patients with generalized neurologic or acute medical, nonneurologic syndromes.
Physicians practicing in the ED are sensitive for stroke/TIA diagnosis. The modest positive predictive value argues for a systems approach with neurology support so that proper decisions regarding acute stroke therapy can be made.
急性中风治疗在很大程度上依赖于急诊科医生的诊断敏锐度。
在一项基于人群的多民族中风研究中确定这种诊断准确性。
科珀斯克里斯蒂市脑卒中超早期监测（BASIC）项目前瞻性地确定了得克萨斯州一个拥有313,645名居民且无学术医疗中心的城市县内所有急性中风或短暂性脑缺血发作（TIA）病例。病例由获得委员会认证的神经科医生使用原始文件进行验证。病例验证被用作金标准来比较急诊科医生给出的诊断。
从2000年1月至2002年8月，共筛查了13,015名患者。其中，1800例被验证为中风/TIA。急诊科医生对经BASIC验证的诊断的总体敏感度为92%，阳性预测值为89%。在急诊科医生认为是中风的病例中，11%被验证为非中风。在多变量模型中，运动症状是防止急诊科对中风/TIA诊断出现假阴性的独立预测因素（比值比[OR]=0.61；95%置信区间0.41至0.89）。感觉症状（OR=0.43；95%置信区间0.28至0.66）、运动症状（OR=0.44；95%置信区间0.32至0.62）和严重神经功能缺损（OR=0.33；95%置信区间0.14至0.78）可预测防止中风/TIA诊断出现假阳性。中风/TIA病史可预测中风诊断出现假阳性（OR=1.72；95%置信区间1.23至2.40）。大多数分歧发生在患有全身性神经或急性内科非神经综合征的患者中。
在急诊科执业的医生对中风/TIA诊断较为敏感。适度的阳性预测值表明需要一种有神经科支持的系统方法，以便能够就急性中风治疗做出正确决策。
