Misdiagnosis of stroke in tissue plasminogen activator-treated patients: characteristics and outcomes.
OBJECTIVE
Misdiagnosis of acute ischemic stroke is a risk inherent in treating patients with acute deficits, yet few data exist on the problem. We report an evaluation of emergency department misdiagnoses in patients treated with tissue plasminogen activator for acute ischemic stroke.


METHODS
We conducted an observational study of 151 consecutive patients treated without an acute stroke team. Initial diagnosis was compared with interim and hospital discharge diagnoses. Separate analyses were performed for patients without a final diagnosis of acute ischemic stroke and for those without a final diagnosis of either acute ischemic stroke or transient ischemic attack, combined.


RESULTS
Ten of 151 patients (7%; 95% confidence interval [CI] 3% to 12%) had final diagnoses that did not include acute ischemic stroke. Six of 151 (4%; 95% CI 1% to 8%) had a final diagnosis other than acute ischemic stroke or transient ischemic attack (conversion disorder [4], complex migraine [1], and Todd's paralysis [1]). These "stroke mimics" had no intracranial hemorrhage (0%; 95% CI 0% to 31%), had less disability at discharge (modified Rankin Scale score mean+/-SD, 2.2+/-1.3 versus 3.2+/-1.8), and were younger (mean age+/-SD, 47+/-21 years versus 68+/-15 years) than patients with acute ischemic stroke or transient ischemic attack. An additional 4 (3%) patients had interim diagnoses other than acute ischemic stroke, all subsequently changed to acute ischemic stroke after magnetic resonance imaging or computed tomography.


CONCLUSIONS
These data show that in a 4-hospital system without an acute stroke team, thrombolytic treatment of patients with diagnoses mimicking stroke was infrequent, and hemorrhagic complications did not occur in any patients without an acute ischemic stroke. However, because the number of mimics was small, safety cannot be ensured with statistical confidence.
Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109-0303, USA. phillip.scott@umich.edu
Phillip A
PA
Scott
Robert
R
Silbergleit
D000046:Academic Medical Centers; D000328:Adult; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D002543:Cerebral Hemorrhage / Q000139:chemically induced; D003951:Diagnostic Errors / Q000009:adverse effects / Q000706:statistics & numerical data*; D006233:Persons with Disabilities / Q000706:statistics & numerical data; D004638:Emergency Treatment / Q000592:standards / Q000706:statistics & numerical data; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006764:Hospitals, Community; D006784:Hospitals, Teaching; D006801:Humans; D015994:Incidence; D008279:Magnetic Resonance Imaging; D008824:Michigan / Q000453:epidemiology; D008875:Middle Aged; D010348:Patient Care Team; D010351:Patient Discharge / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000009:adverse effects / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator