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Inter-rater Agreement for the Diagnosis of Stroke Versus Stroke Mimic

Liberman, Ava L., MD*; Rostanski, Sara K., MD; Ruff, Ilana M., MD; Meyer, Ashley N.D., PhD§,∥; Maas, Matthew B., MD; Prabhakaran, Shyam, MD, MS


In an article appearing in July 2018, information was missing. The below statements should be added to the first page footnote:

Dr. Meyer is funded by the VA National Center for Patient Safety (XVA 33-105) and the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN13-413).

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

These errors have been noted in the online version of this article, which is available at .

The Neurologist. 23(5):181, September 2018.

doi: 10.1097/NRL.0000000000000187
Original Articles

Background and Purpose: Patients who present emergently with acute neurological signs and symptoms represent unique diagnostic challenges for clinicians. We sought to characterize the reliability of physician diagnosis in differentiating aborted or imaging-negative acute ischemic stroke from stroke mimic.

Methods: We constructed 10 case-vignettes of patients treated with thrombolysis with subsequent clinical improvement who lacked radiographic evidence of infarction. Using an online survey, we asked physicians to select a most likely final diagnosis after reading each case-vignette. Inter-rater agreement was evaluated using percent agreement and κ statistic for multiple raters with 95% confidence intervals reported.

Results: Sixty-five physicians participated in the survey. Most participants were in practice for ≥5 years and over half were vascular neurologists. Physicians agreed on the most likely final diagnosis 71% of the time, κ of 0.21 (95% confidence interval, 0.06-0.54). Percent agreement was similar across participant practice locations, years of experience, subspecialty training, and personal experience with thrombolysis.

Conclusions: We found modest agreement among surveyed physicians in distinguishing ischemic stroke syndromes from stroke mimics in patients without radiographic evidence of infarction and clinical improvement after thrombolysis. Methods to improve diagnostic consensus after thrombolysis are needed to assure acute ischemic stroke patients and stroke mimics are treated safely and accurately.

*Department of Neurology, Albert Einstein College of Medicine, Bronx

Department of Neurology, New York University, New York, NY

Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL

§Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center

Department of Medicine, Baylor College of Medicine, Houston, TX

The authors declare no conflict of interest.

Reprints: Ava L. Liberman, MD, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, 4th floor, Bronx, NY 10467. E-mail:

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