This article will help you avoid misdiagnosis of stroke in the emergency room |

Stroke is a common disease in the emergency department of neurology.
Patients with symptoms such as focal neurological deficits, dizziness and headache are even more commonplace in the emergency department of neurology.

However, in addition to stroke, migraines, seizures, and other conditions may also cause patients to go to the neurological emergency department, and may be confused with stroke.

In an emergency setting, it is essential to make rapid clinical reasoning based on the patient's symptoms.

This article will introduce some diagnostic techniques for emergency stroke.

Misdiagnosis of stroke can be roughly divided into two categories, one is a false negative diagnosis, that is, underdiagnosis; the other is a false positive diagnosis, that is, overdiagnosis.

In the emergency setting, the difficulty in the diagnosis and treatment of stroke is that some other acute neurological diseases focus on emergency management measures, but the disease of stroke requires urgent confirmation of the diagnosis.

In differential diagnosis, medical history collection and physical examination are the basis of everything.
First, we organize the main points of the differential diagnosis of medical history and physical examination in the form of a table, and then introduce some minor problems in the diagnosis of stroke to assist everyone in the correct diagnosis of stroke.
, And correctly understand the misdiagnosis of stroke.

Which main complaints will pose challenges for stroke diagnosis? Several studies have shown that changes in mental status and decreased levels of consciousness are one of the most prone to misdiagnosis.
On the one hand, it may be because the focal neurological symptoms of such patients are difficult to identify, and on the other hand, when patients suffer from aphasia , May also be mistaken for a state of consciousness issue.

Vertigo is also a challenging symptom that may lead to misdiagnosis of stroke.
The retrospective description of the symptoms of vertigo often differs from the actual situation.
However, doctors conduct systematic interviews and physical examinations of patients with vertigo, including HINTS examinations.
Other methods can help clarify the cause of vertigo symptoms.

Headache is also a tricky complaint.

The proportion of stroke patients with headache complaints is about 18% to 32%.
Compared with patients with ischemic stroke, patients with hemorrhagic stroke and cerebral venous thrombosis are more likely to complain of headache.

Headaches in stroke patients are often bilateral, and may be relieved over time when the stroke occurs.

Among headache-related diseases, hemiplegic migraine is one of the diseases most easily confused with stroke.

Is neuroimaging always useful to distinguish stroke? The overestimation of neuroimaging sensitivity may be a factor in the missed diagnosis of stroke.

It is needless to say that the sensitivity of head CT in the early diagnosis of ischemic stroke is low.
Even MRI may not guarantee the sensitivity.
According to statistics, nearly 1/3 of patients with non-disabling ischemic stroke Of patients lack evidence of acute ischemia on MRI.

In addition, for patients with dizziness as the main complaint, clinicians are also easy to take it lightly.

In the case of a suspected stroke, the following flow chart helps to select patients for thrombolytic therapy.

In addition to neuroimaging, some scholars are now focusing on the study of serum biomarkers to distinguish the cause of acute ischemic stroke and identify patients with non-ischemic events, or to help improve the accuracy of acute stroke diagnosis.
Let us It is expected that the results of these studies will bring more convenient detection methods.

What happens if the patient receives thrombolysis by mistake? In the patient registration study of thrombolytic therapy in large hospitals, non-stroke patients receiving thrombolytic therapy accounted for 1% to 16%.

One analysis showed that in such non-stroke patients, the proportion of symptomatic intracranial hemorrhage was only 0.
5%, while the proportion of stroke patients was 4%.

However, studies have shown that if a patient receives a stroke thrombolysis due to a misdiagnosis, the hospital admission fee will exceed the normal expenditure by 5,400 US dollars.

In fact, as people increasingly pursue rapid stroke diagnosis, the misdiagnosis rate may also increase.

Studies have shown that after the improvement of the treatment process of acute stroke through optimization measures, although the door-to-needle time (DNT) of stroke patients has been reduced, the proportion of non-stroke patients receiving thrombolysis has increased.

Whether the need for rapid stroke treatment will affect the diagnosis decision of acute ischemic stroke still needs further research.

Summary Although misdiagnosis can never be completely eliminated, we can use some methods to optimize the diagnosis process of stroke.

On the one hand, clinicians must hone their sharp eyes, and on the other hand, they must find a balance between rapid diagnosis and correct diagnosis.

Yimaitong compiled from: Liberman AL, Prabhakaran S.
Stroke Chameleons and Stroke Mimics in the Emergency Department[J].
Current Neurology & Neuroscience Reports, 2017, 17(2):15.