title: The accuracy of prehospital diagnosis of acute cerebrovascular accidents: an observational study.
abstract: BACKGROUND
  Time to treatment is the key factor in stroke care. Although the initial medical assessment is usually made by a non-neurologist or a paramedic, it should ensure correct identification of all acute cerebrovascular accidents (CVAs). Our aim was to evaluate the accuracy of the physician-made prehospital diagnosis of acute CVA in patients referred directly to the neurological emergency department (ED), and to identify conditions mimicking CVAs.
  
  
  METHODS
  This observational study included consecutive patients referred to our neurological ED by emergency physicians with a suspicion of CVA (acute stroke, transient ischemic attack (TIA) or a syndrome-based diagnosis) during 12 months. Referrals were considered correct if the prehospital diagnosis of CVA proved to be stroke or TIA.
  
  
  RESULTS
  The prehospital diagnosis of CVA was correct in 360 of 570 cases. Its positive predictive value ranged from 100% for the syndrome-based diagnosis, through 70% for stroke, to 34% for TIA. Misdiagnoses were less frequent among ambulance physicians compared to primary care and outpatient physicians (33% vs. 52%, p < 0.001). The most frequent mimics were vertigo (19%), electrolyte and metabolic disturbances (12%), seizures (11%), cardiovascular disorders (10%), blood hypertension (8%) and brain tumors (5%). Additionally, 6% of all admitted CVA cases were referred with prehospital diagnoses other than CVA.
  
  
  CONCLUSIONS
  Emergency physicians appear to be sensitive in diagnosing CVAs but their overall accuracy does not seem high. They tend to overuse the diagnosis of TIA. Constant education and adoption of stroke screening scales may be beneficial for emergency care systems based both on physicians and on paramedics.
authors.affiliation: 2 Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.
authors.forename: Michał
authors.initials: M
authors.lastname: Karliński
authors.affiliation: 2 Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.
authors.forename: Marcin
authors.initials: M
authors.lastname: Gluszkiewicz
authors.affiliation: 2 Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.
authors.forename: Anna
authors.initials: A
authors.lastname: Członkowska
keywords: emergency medical services; misdiagnosis; prehospital management; stroke; transient ischemic attack