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Diagnosing Stroke in the ED

Diagnosing Stroke in the ED

Studies suggest that there are missed opportunities to diagnose cerebrovascular causes for stroke symptoms. “While traditional stroke symptoms are rarely missed,” says David E. Newman-Toker, MD, PhD, “clinicians can sometimes overlook or discount non-specific symptoms, such as dizziness or headache.” Quantifying Misdiagnoses In the journal Diagnosis, Dr. Newman-Toker and colleagues recently published a study estimating the likelihood of missed stroke in the ED. The study also looked at associations with patient, hospital, and ED visit characteristics and calculated the odds of missed stroke within those domains. Using federal healthcare data, the researchers identified adults admitted for stroke with a treat-and-release ED visit in the prior 30 days. Up to 12.7% of patients who were later admitted for stroke had been potentially misdiagnosed and erroneously sent home from the ED in the 30 days before being hospitalized for stroke. “Patients who were misdiagnosed for stroke disproportionately presented with dizziness or headaches,” says Dr. Newman-Toker. About half of the unexpected returns for stroke occurred within 7 days, and more than half occurred in the first 48 hours. Women and minorities were more likely to be misdiagnosed. People younger than 45 were about seven times more likely to be given an incorrect diagnosis and sent home without treatment. “Based on our data, the estimated number of missed strokes resulting in harm to patients in the U.S. could be anywhere between 15,000 and 165,000 annually,” says Dr. Newman-Toker. “That’s a wide range, but the number is likely between 50,000 and 100,000 per year when all of the variables are taken into consideration.” He notes that it is challenging to ascertain more specific estimates...
An Innovation in Diagnosing Stroke

An Innovation in Diagnosing Stroke

Vertigo and dizziness account for 4 million ED visits per year in the United States, about 5% of which are attributable to stroke. Some patients present to the ED with acute vestibular syndrome (AVS), a condition that involves severe, continuous vertigo or dizziness, nausea or vomiting, gait instability, head motion intolerance, and nystagmus that can last from days to weeks. While most AVS cases have benign causes (vestibular neuritis or labyrinthitis), about 25% are caused from the brain stem or cerebellar strokes. “Distinguishing strokes causing AVS can be challenging for ED physicians because signs and symptoms mirror benign conditions,” says David E. Newman-Toker, MD. CT and MRI with diffusion-weighted imaging are typically used to detect stroke, but these tests still miss a large number of strokes within 48 hours of symptom onset. Eye Movements Matter Studies have shown that bedside eye movement findings can help differentiate causes of AVS as being either stroke or a benign inner ear lesion. Eye movement tests can be applied rapidly and are noninvasive, but they are unfamiliar to most non-specialists. Recently, an easy-to-use video-oculography device that is lightweight, portable, and noninvasive has been developed. It has been shown to accurately measure the key eye movements under controlled laboratory conditions. “If video-oculography can work similarly in clinical practice, it could lead to earlier stroke diagnoses and more efficient ED testing and triage decisions for patients with acute vertigo and dizziness,” says Dr. Newman-Toker. “Fully automating the device for use in EDs might eventually mean the technology can be used without onsite expertise. Such an approach would be analogous to diagnosing a heart attack by...
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