From the Research Programs Unit (S.P., O.S.M., J.R., P.J.L.), Molecular Neurology, University of Helsinki; Clinical Neurosciences, Neurology (O.S.M., G.S., S.C., D.S., T.T., P.J.L.), and Department of Emergency Medicine and Services, Section of Emergency Medical Services (H.H., M.P., M.K.), University of Helsinki and Helsinki University Hospital, Finland; Department of Clinical Neuroscience/Neurology (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg; and Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden.
Neurology. 2018 Aug 7;91(6):e498-e508. doi: 10.1212/WNL.0000000000005954. Epub 2018 Jul 11.
To clarify diagnostic accuracy and consequences of misdiagnosis in the admission evaluation of stroke-code patients in a neurologic emergency department with less than 20-minute door-to-thrombolysis times.
Accuracy of admission diagnostics was studied in an observational cohort of 1,015 stroke-code patients arriving by ambulance as candidates for recanalization therapy between May 2013 and November 2015. Immediate admission evaluation was performed by a stroke neurologist or a neurology resident with dedicated stroke training, primarily utilizing CT-based imaging.
The rate of correct admission diagnosis was 91.1% (604/663) for acute cerebral ischemia (ischemic stroke/TIA), 99.2% (117/118) for hemorrhagic stroke, and 61.5% (144/234) for stroke mimics. Of the 150 (14.8%) misdiagnosed patients, 135 (90.0%) had no acute findings on initial imaging and 100 (67.6%) presented with NIH Stroke Scale score 0 to 2. Misdiagnosis altered medical management in 70 cases, including administration of unnecessary treatments (thrombolysis n = 13, other n = 24), omission of thrombolysis (n = 5), delays to specific treatments of stroke mimics (n = 13, median 56 [31-93] hours), and delays to antiplatelet medication (n = 14, median 1 [1-2] day). Misdiagnosis extended emergency department stay (median 6.6 [4.7-10.4] vs 5.8 [3.7-9.2] hours; = 0.001) and led to unnecessary stroke unit stay (n = 10). Detailed review revealed 8 cases (0.8%) in which misdiagnosis was possible or likely to have worsened outcomes, but no death occurred as a result of misdiagnosis.
Our findings support the safety of highly optimized door-to-needle times, built on thorough training in a large-volume, centralized stroke service with long-standing experience. Augmented imaging and front-loaded specialist engagement are warranted to further improve rapid stroke diagnostics.
在 20 分钟内进行溶栓治疗的神经科急诊卒中编码患者入院评估中，明确诊断准确性和误诊的后果。
在 2013 年 5 月至 2015 年 11 月期间，通过救护车到达并接受再通治疗候选的 1015 例卒中编码患者的观察队列中，研究了入院诊断的准确性。由卒中神经病学家或接受专门卒中培训的神经科住院医师立即进行入院评估，主要利用 CT 成像。
急性脑缺血（缺血性卒中和 TIA）的正确入院诊断率为 91.1%（604/663），出血性卒中为 99.2%（117/118），卒中模拟为 61.5%（144/234）。150 例（14.8%）误诊患者中，135 例（90.0%）初始影像学无急性发现，100 例（67.6%）NIH 卒中量表评分为 0-2。误诊改变了 70 例患者的治疗管理，包括不必要的治疗（溶栓 n=13，其他 n=24）、漏用溶栓（n=5）、延误卒中模拟的特定治疗（n=13，中位数 56[31-93]小时）和延误抗血小板药物治疗（n=14，中位数 1[1-2]天）。误诊延长了急诊停留时间（中位数 6.6[4.7-10.4] vs 5.8[3.7-9.2]小时；=0.001），并导致不必要的卒中单元停留（n=10）。详细回顾显示，有 8 例（0.8%）误诊可能或可能导致预后恶化，但无误诊导致死亡。
我们的发现支持在经过大量培训的、集中化的卒中服务中心，基于严格的流程管理和长期经验的基础上，实现高度优化的门到针时间的安全性。需要增强影像学检查和提前配备专家参与，以进一步提高快速卒中诊断。
