Background: Failure to recognise acute stroke may result in worse outcomes due to missed opportunity for acute stroke therapies. Our study examines factors associated with stroke misdiagnosis in patients admitted to a large comprehensive stroke centre. Methods: Retrospective review comparing 156 consecutive stroke patients misdiagnosed in emergency department (ED) with 156 randomly selected stroke controls matched for age, gender, language spoken and stroke subtype for the period 2014–2016. Results: There were 141 ischemic and 15 hemorrhagic misdiagnosed strokes (median age: 77 years, male:female = 1.3: 1). Symptom resolution, altered mental status, nausea/vomiting, dizziness and vertigo favored misdiagnosis (p < 0.05). Hemiparesis and dysarthria favored an accurate diagnosis (p < 0.05). Misdiagnosed patients were more commonly triaged into a lower ED category (62 vs. 42%, p = 0.001), clinically assessed as Face, Arm, Speech and Time (FAST) – negative (78 vs. 22%, p < 0.001) and underwent delayed CT imaging (median 4.1 vs. 1.5 h, p < 0.001). Misdiagnosed patients were more likely to have posterior circulation stroke (PCS; 39 vs. 22%, = 0.01) and be admitted under non-neurological services (35 vs. 11%, p < 0.001) with worse discharge outcomes including increased mortality. Conclusions: Patients with stroke misdiagnosis were commonly FAST-negative with nonspecific symptoms including altered mental status, dizziness and nausea/vomiting often associated with PCS. Improved diagnostic accuracy may increase access to acute therapies.

1.
Stroke Foundation: No postcode untouched. Stroke in Australia, 2017.
2.
National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group: Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581–1587.
3.
Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al: Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387: 1723–1731.
4.
Sevick LK, Ghia S, Hill MD, Danthurebandara V, Lorenzetti DL, Noseworthy T, et al: Systematic review of the cost and cost-effectiveness of rapid endovascular therapy for acute ischaemic stroke. Stroke 2017; 48: 2519–2526.
5.
Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE: ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Neurology 2017; 88: 1468–1477.
6.
Cadilhac DA, Andrew NE, Lannin NA, Middleton S, Levi CR, Dewey HM, et al: Quality of acute care and long-term quality of life and survival: The Australian Stroke Clinical Registry. Stroke 2017; 48: 1026–1032.
7.
Liberman AL, Prabhakaran S: Stroke chameleons and stroke mimics in the Emergency Department. Curr Neurol Neurosci Rep 2017; 17: 15.
8.
Richoz B, Hugli O, Dami F, Carron PN, Faouzi M, Michel P: Acute stroke chameleons in a university hospital: risk factors, circumstances, and outcomes. Neurology 2015; 85: 505–511.
9.
Madsen TE, Khoury J, Cadena R, Adeoye O, Alwell KA, Moomaw CJ, et al: Potentially missed diagnosis of ischemic stroke in the Emergency Department in the Greater Cincinnati/Northern Kentucky Stroke Study. Acad Emerg Med 2016; 23: 1128–1135.
10.
Arch AE, Weisman DC, Coca S, Nystrom KV, Wira CR 3rd, Schindler JL: Missed ischemic stroke diagnosis in the Emergency Department by Emergency Medicine and Neurology Services. Stroke 2016; 47: 668–673.
11.
Calic Z, Cappelen-Smith C, Anderson CS, Xuan W, Cordato DJ: Cerebellar infarction and factors associated with delayed presentation and misdiagnosis. Cerebrovasc Dis 2016; 42: 476–484.
12.
Masuda Y, Tei H, Shimizu S, Uchiyama S: Factors associated with the misdiagnosis of cerebellar infarction. J Stroke Cerebrovasc Dis 2013; 22: 1125–1130.
13.
Sheppard JP, Mellor RM, Greenfield S, Mant J, Quinn T, Sandler D, et al: The association between prehospital care and in-hospital treatment decisions in acute stroke: a cohort study. Emerg Med J 2015; 32: 93–99.
14.
Bisdorff AR, Staab JP, Newman-Toker DE: Overview of the international classification of vestibular disorders. Neurol Clin 2015; 33: 541–550.
15.
Adams HP Jr, Davis PH, Leira EC, Chang KC, Bendixen BH, Clarke WR, et al: Baseline NIH Stroke Scale score strongly predicts outcome after stroke: a report of the TOAST. Neurology 1999; 53: 126–131.
16.
Tao WD, Liu M, Fisher M, Wang DR, Li J, Furie KL, et al: Posterior versus anterior circulation infarction: how different are the neurological deficits? Stroke 2012; 43: 2060–2065.
17.
Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE: HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009; 40: 3504–3510.
18.
Wolters FJ, Paul NL, Li L, Rothwell PM; Oxford Vascular Study: Sustained impact of UK FAST-test public education on response to stroke: a population-based time-series study. Int J Stroke 2015; 10: 1108–1114.
19.
Aroor S, Singh R, Goldstein LB: BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): reducing the proportion of strokes missed using the FAST mnemonic. Stroke 2017; 48: 479–481.
20.
Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al: Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018; 378: 11–21.
21.
Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al: Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018; 378: 708–718.
22.
Holt PJ, Sinha S, Ozdemir BA, Karthikesalingam A, Poloniecki JD, Thompson MM: Variations and inter-relationship in outcome from emergency admissions in England: a retrospective analysis of Hospital Episode Statistics from 2005–2010. BMC Health Serv Res 2014; 14: 270.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.