SAN DIEGO—Stroke symptoms are often underappreciated in patients under age 50, according to investigators who found that young adult stroke patients may be misdiagnosed in the emergency department, where the error is considered vertigo, alcohol intoxication, or something else.
As a result, the patients may fail to receive thrombolytic therapy, even though they arrived at the hospital within the three-hour treatment window, said lead study author Seemant Chaturvedi, MD, professor of neurology at Wayne State University and director of the Wayne State University/Detroit Medical Center Stroke Program.
Speaking here at the American Stroke Association International Stroke Conference in February, he said: “Some are discharged and return a few days later with worsening symptoms. Only then is stroke correctly diagnosed.”
For the study, the researchers reviewed data on 57 patients, aged 18 to 48, enrolled since 2001 in the Young Stroke Registry at the Comprehensive Stroke Center at Wayne State University in Detroit: 39 were white, 17 were African-American, and one was Asian; 34 were women.
Four men and four women (14 percent), average age 34, were misdiagnosed as having benign positional vertigo, alcohol intoxication, or other conditions. They were discharged from the hospital and later discovered to have suffered a stroke.
“All eight patients had classic stroke symptoms once we looked into it,” Dr. Chaturvedi said.
For example, a 44-year-old woman had sudden onset of nausea and vertigo while teaching and was brought to a suburban emergency room within the three-hour treatment window, but was diagnosed as having an inner ear disorder and discharged. Continuing to have vertigo, the woman was seen at the same hospital two days later. Brain MRI revealed she had suffered a left posterior inferior cerebellar artery infarct.
In another case, a 28-year-old women who reported seeing “spots” while putting on facial makeup, went to the local community hospital emergency room complaining of the “worst headache of her life — starting in the right neck and radiating to the right temporal and frontal regions,” Dr. Chaturvedi said. “There was also associated severe dizziness and a tendency to fall.”
A subarachnoid hemorrhage was excluded after brain CT and lumbar puncture for CSF examination proved negative. She was discharged to home, only to be readmitted with continued nausea and vomiting. An MRI showed right lateral medullary and cerebellar infarcts and right vertebral artery dissection.
Figure. DR. SEEMANT ...Image Tools
Other patients were misdiagnosed as having labyrinthitis, migraine, and new-onset seizure with prolonged postictal state, according to Dr. Chaturvedi. Seven of the eight patients were potential candidates for tissue plasminogen activator (tPA) treatment. “Only one patient arrived after six hours,” he said.
Among other findings, six of the eight misdiagnosed patients proved to have vertebrobasilar territory strokes, he said. Three strokes were due to dissection, two were cryptogenic, and one each was caused by atherosclerosis, small vessel disease, and suspected Sneddon syndrome.
All eight patients with missed diagnoses were initially evaluated at hospital emergency rooms that were not certified as Joint Commission Primary Stroke Centers. Age did appear to play a role, with 33 percent of people under age 35 misdiagnosed versus nine percent of those age 35 and older. “This reached borderline significance,” Dr. Chaturvedi said.
Also, 35 percent of posterior circulation strokes were misdiagnosed, compared with five percent of anterior circulation strokes, a significant difference.
“If there is sudden onset of nausea and vomiting and unsteady gait or visual problems, you should suspect stroke and order an urgent MRI. It shows stroke within the first six to eight hours and CT often doesn't,” he told Neurology Today.
There are at least 10,000 to 15,000 strokes per year among Americans aged 16 to 50, Dr. Chaturvedi said.
Commenting on the study, Jeffrey L. Saver, MD, professor of neurology at the University of California-Los Angeles (UCLA) School of Medicine, director of the UCLA Stroke Center, and medical director of the Stroke Unit at UCLA Medical Center, said, “This is a very useful study that highlights a problem that occurs all too commonly.”
Noting that stroke is twice as common in midlife as multiple sclerosis, Dr. Saver said: “When patients in the emergency room present with new-onset neurological symptoms, stroke should always be part of the [differential] diagnosis.
“One simple way to distinguish between stroke and other conditions is to evaluate whether the patient has difficulty walking. Don't send patients out of the emergency department until you know they can walk,” he said.
The fact that all the misdiagnosed patients were initially evaluated at emergency rooms that were not certified as stroke centers points to the need for “telestroke” systems, in which remote neurologists can help to diagnose patients, Dr. Saver added. “There just aren't enough neurologists for every rural emergency room,” he said.
Mark J. Alberts, MD, professor of neurology and director of the Stroke Program at Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital in Chicago, agreed. “This has been our experience [at Northwestern] as well. Younger patients come in with dizziness and unsteadiness and are misdiagnosed as having ear problems or alcohol intoxication when in fact they are having a stroke,” he said.
“That said, people come in with dizziness all the time and the vast majority are not having a stroke and it's not feasible to do an MRI on all of them,” Dr. Alberts continued.
Careful clinical evaluation can help to sort out which patients are actually having a stroke, he said. “For example, stroke patients usually have abnormal gait and coordination, while ear problems may just present as dizziness,” Dr. Alberts said.