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Diagnosing cerebral ischemia with door-to-thrombolysis times below 20 minutes.
Pihlasviita, Saana; Mattila, Olli S; Ritvonen, Juhani; Sibolt, Gerli; Curtze, Sami; Strbian, Daniel; Harve, Heini; Pystynen, Mikko; Kuisma, Markku; Tatlisumak, Turgut; Lindsberg, Perttu J.
Afiliação
  • Pihlasviita S; 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.), Universi
  • Mattila OS; 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.), Universi
  • Ritvonen J; 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.), Universi
  • Sibolt G; 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.), Universi
  • Curtze S; 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.), Universi
  • Strbian D; 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.), Universi
  • Harve H; 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.), Universi
  • Pystynen M; 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.), Universi
  • Kuisma M; 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.), Universi
  • Tatlisumak T; 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.), Universi
  • Lindsberg PJ; 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.), Universi
Neurology ; 91(6): e498-e508, 2018 08 07.
Article em En | MEDLINE | ID: mdl-29997196
ABSTRACT

OBJECTIVES:

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.

METHODS:

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.

RESULTS:

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; p = 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.

CONCLUSIONS:

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.
Assuntos

Texto completo: 1 Coleções: 01-internacional Base de dados: MEDLINE Assunto principal: Terapia Trombolítica / Isquemia Encefálica / Acidente Vascular Cerebral / Tempo para o Tratamento Tipo de estudo: Diagnostic_studies / Etiology_studies / Incidence_studies / Observational_studies / Risk_factors_studies / Screening_studies Limite: Aged / Aged80 / Female / Humans / Male / Middle aged Idioma: En Revista: Neurology Ano de publicação: 2018 Tipo de documento: Article

Texto completo: 1 Coleções: 01-internacional Base de dados: MEDLINE Assunto principal: Terapia Trombolítica / Isquemia Encefálica / Acidente Vascular Cerebral / Tempo para o Tratamento Tipo de estudo: Diagnostic_studies / Etiology_studies / Incidence_studies / Observational_studies / Risk_factors_studies / Screening_studies Limite: Aged / Aged80 / Female / Humans / Male / Middle aged Idioma: En Revista: Neurology Ano de publicação: 2018 Tipo de documento: Article