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Early stroke signs often overlooked in emergency departments

The authors estimated that 15,000–165,000 misdiagnosed strokes occur annually in United States emergency departments; most cases are diagnosed as headache or dizziness
The authors estimated that 15,000–165,000 misdiagnosed strokes occur annually in United States emergency departments; most cases are diagnosed as headache or dizzinessRobin Wulffson, MD

According to a new study, the early symptoms of a stroke are often overlooked by healthcare professionals in a hospital emergency department. Furthermore, early stroke symptoms are more likely to be overlooked in minorities, women, and patients under age 45. The findings were published online on April 3 in the journal Diagnosis by researchers at Johns Hopkins University School of Medicine in Baltimore, Maryland.

The study authors note that misdiagnosis, in general, may account for 40,000–80,000 preventable deaths each year in US hospitals; in addition, the error probably accounts for a comparable amount of disability. Stroke is one of the most common dangerous missed diagnoses. Approximately 800,000 Americans suffer a stroke each year at a cost of more than $40 billion. In addition, another 200,000–500,000 individuals suffer a transient ischemic attack (TIA), which is an indication of impending stroke. Stroke is a leading cause of serious disability and death in the US and worldwide. Numerous studies has found that prompt treatment improves stroke outcomes and lowers the risk of a recurrent stroke risk by as much as 80%; therefore, timely intervention is extremely important.

The researchers conducted a cross-sectional analysis by reviewing inpatient discharge and emergency department records from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases and 2008–2009 State Emergency Department Databases from nine US states. They identified adult patients who were admitted for stroke who had undergone a treat-and-release emergency department visit in the prior 30 days; these patients were given a non-stroke diagnosis such as headache or dizziness.

The investigators located 23,809 potential and 2,243 probable missed strokes that signified 12.7% and 1.2% of stroke admissions, respectively. Missed hemorrhagic strokes (rupture of a blood vessel in the brain; 406 patients) were misdiagnosed as headache while missed ischemic strokes (blockage of a blood vessel in the brain; 1,435 patients) and transient ischemic attacks (402 patients) were misdiagnosed as headache or dizziness. The odds of a probable misdiagnosis were lower among men (0.75-fold less risk), older individuals (age 45–64: 0.43-fold less risk; age 65–74; 0.28-fold less risk), and Medicare (0.66-fold less risk) or Medicaid (0.70-fold less risk) recipients compared to privately insured patients. The odds of a misdiagnosis were higher among African Americans (1.18-fold increased risk), Asian/Pacific Islanders (1.29-fold increased risk), and Hispanics (1.30-fold increased risk). The odds of a misdiagnosis were higher in non-teaching hospitals (1.45-fold increased risk) and low-volume hospitals (1.57-fold increased risk).

The authors estimated that 15,000–165,000 misdiagnosed strokes occur annually in United States emergency departments; most cases are diagnosed as headache or dizziness. They recommended that physicians evaluating these symptoms should be particularly attentive to the possibility of stroke in younger, female, and non-Caucasian patients.

Take home message:

Today’s hospital emergency departments are extremely busy; sadly, many patients who present at them have a minor problem. This places a burden on the staff who must separate those that actually have a serious problem. Often, a friend or relative accompanies a patient to an emergency department. These individuals must serve as the patient’s advocate and alert the medical staff to the possibility of a stroke.

The following are the most common symptoms of stroke. However, each individual may experience symptoms differently. Symptoms may be sudden and include:

  • Weakness or numbness of the face, arm, or leg, especially on one side of the body
  • Confusion or difficulty speaking or understanding
  • Problems with vision such as dimness or loss of vision in one or both eyes
  • Dizziness or problems with balance or coordination
  • Problems with movement or walking
  • Severe headaches with no other known cause

All of the above warning signs may not occur with each stroke. Do not ignore any of the warning signs, even if they go away––take action immediately. The symptoms of stroke may resemble other medical conditions or problems.

  • Other, less common, symptoms of stroke may include the following:
  • Sudden nausea, vomiting, or fever not caused by a viral illness
  • Brief loss or change of consciousness such as fainting, confusion, seizures, or coma
  • Transient ischemic attack (TIA)

A TIA can cause many of the same symptoms as a stroke, but TIA symptoms are transient and last for a few minutes or up to 24 hours. Call for medical help immediately if you suspect a person is having a TIA, as it may be a warning sign that a stroke is about to occur. Not all strokes, however, are preceded by TIAs.