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August 07, 2018; 91 (6) Article

Diagnosing cerebral ischemia with door-to-thrombolysis times below 20 minutes

Saana Pihlasviita, Olli S. Mattila, Juhani Ritvonen, Gerli Sibolt, Sami Curtze, Daniel Strbian, Heini Harve, Mikko Pystynen, Markku Kuisma, Turgut Tatlisumak, Perttu J. Lindsberg
First published July 11, 2018, DOI: https://doi.org/10.1212/WNL.0000000000005954
Saana Pihlasviita
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.
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Olli S. Mattila
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.
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Juhani Ritvonen
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.
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Gerli Sibolt
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.
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Sami Curtze
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.
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Daniel Strbian
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.
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Heini Harve
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.
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Mikko Pystynen
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.
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Markku Kuisma
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.
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Turgut Tatlisumak
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.
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Perttu J. Lindsberg
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.
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Diagnosing cerebral ischemia with door-to-thrombolysis times below 20 minutes
Saana Pihlasviita, Olli S. Mattila, Juhani Ritvonen, Gerli Sibolt, Sami Curtze, Daniel Strbian, Heini Harve, Mikko Pystynen, Markku Kuisma, Turgut Tatlisumak, Perttu J. Lindsberg
Neurology Aug 2018, 91 (6) e498-e508; DOI: 10.1212/WNL.0000000000005954

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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.

Glossary

ACI=
acute cerebral ischemia;
DNT=
door-to-needle time;
ED=
emergency department;
EMS=
emergency medical services;
HS=
hemorrhagic stroke;
ICH=
intracerebral hemorrhage;
IS=
ischemic stroke;
NIHSS=
NIH Stroke Scale;
SC=
stroke-code;
SM=
stroke mimic

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Editorial, page 245

  • Podcast: NPub.org/9uw8lu

  • CME Course: NPub.org/cmelist

  • Received December 29, 2017.
  • Accepted in final form April 24, 2018.
  • © 2018 American Academy of Neurology
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