Faculty Bibliography

BACKGROUND:Missed or delayed diagnosis of acute stroke, or false-negative stroke (FNS), at initial emergency department (ED) presentation occurs in ≈9% of confirmed stroke patients. Failure to rapidly diagnose stroke can preclude time-sensitive treatments, resulting in higher risks of severe sequelae and disability. In this study, we developed and tested a modified version of a structured medical record review tool, the Safer Dx Instrument, to identify FNS in a subgroup of hospitalized patients with stroke to gain insight into sources of ED stroke misdiagnosis. METHODS:We conducted a retrospective cohort study at 2 unaffiliated comprehensive stroke centers. In the development and confirmatory cohorts, we applied the Safer Stroke-Dx Instrument to report the prevalence and documented sources of ED diagnostic error in FNS cases among confirmed stroke patients upon whom an acute stroke was suspected by the inpatient team, as evidenced by stroke code activation or urgent neurological consultation, but not by the ED team. Inter-rater reliability and agreement were assessed using interclass coefficient and kappa values (κ). RESULTS:Among 183 cases in the development cohort, the prevalence of FNS was 20.2% (95% CI, 15.0-26.7). Too narrow a differential diagnosis and limited neurological examination were common potential sources of error. The interclass coefficient for the Safer Stroke-Dx Instrument items ranged from 0.42 to 0.91, and items were highly correlated with each other. The κ for diagnostic error identification was 0.90 (95% CI, 0.821-0.978) using the Safer Stroke-Dx Instrument. In the confirmatory cohort of 99 cases, the prevalence of FNS was 21.2% (95% CI, 14.2-30.3) with similar sources of diagnostic error identified. CONCLUSIONS:Hospitalized patients identified by stroke codes and requests for urgent neurological consultation represent an enriched population for the study of diagnostic error in the ED. The Safer Stroke-Dx Instrument is a reliable tool for identifying FNS and sources of diagnostic error.

OBJECTIVE:To determine the prevalence and associated mortality of well-defined neurologic diagnoses among COVID-19 patients, we prospectively followed hospitalized SARS-Cov-2 positive patients and recorded new neurologic disorders and hospital outcomes. METHODS:We conducted a prospective, multi-center, observational study of consecutive hospitalized adults in the NYC metropolitan area with laboratory-confirmed SARS-CoV-2 infection. The prevalence of new neurologic disorders (as diagnosed by a neurologist) was recorded and in-hospital mortality and discharge disposition were compared between COVID-19 patients with and without neurologic disorders. RESULTS:Of 4,491 COVID-19 patients hospitalized during the study timeframe, 606 (13.5%) developed a new neurologic disorder in a median of 2 days from COVID-19 symptom onset. The most common diagnoses were: toxic/metabolic encephalopathy (6.8%), seizure (1.6%), stroke (1.9%), and hypoxic/ischemic injury (1.4%). No patient had meningitis/encephalitis, or myelopathy/myelitis referable to SARS-CoV-2 infection and 18/18 CSF specimens were RT-PCR negative for SARS-CoV-2. Patients with neurologic disorders were more often older, male, white, hypertensive, diabetic, intubated, and had higher sequential organ failure assessment (SOFA) scores (all P<0.05). After adjusting for age, sex, SOFA-scores, intubation, past history, medical complications, medications and comfort-care-status, COVID-19 patients with neurologic disorders had increased risk of in-hospital mortality (Hazard Ratio[HR] 1.38, 95% CI 1.17-1.62, P<0.001) and decreased likelihood of discharge home (HR 0.72, 95% CI 0.63-0.85, P<0.001). CONCLUSIONS:Neurologic disorders were detected in 13.5% of COVID-19 patients and were associated with increased risk of in-hospital mortality and decreased likelihood of discharge home. Many observed neurologic disorders may be sequelae of severe systemic illness.

BACKGROUND AND PURPOSE/OBJECTIVE:Mechanical thrombectomy (MT) has helped many patients achieve functional independence. The effect of time-to-treatment based in specific epochs and as related to Alberta Stroke Program Early CT Score (ASPECTS) has not been established. The goal of the study was to evaluate the association between last known normal (LKN)-to-puncture time and good functional outcome. METHODS:We conducted a retrospective cohort study of prospectively collected acute ischemic stroke patients undergoing MT for large vessel occlusion. We used binary logistic regression models adjusted for age, Modified Treatment in Cerebral Ischemia score, initial National Institutes of Health Stroke Scale, and noncontrast CT ASPECTS to assess the association between LKN-to-puncture time and favorable outcome defined as Modified Rankin Score 0-2 on discharge. RESULTS:Among 421 patients, 328 were included in analysis. Increased LKN-to-puncture time was associated with decreased probability of good functional outcome (adjusted odds ratio [aOR] ratio per 15-minute delay = .98; 95% confidence interval [CI], .97-.99; P = .001). This was especially true when LKN-puncture time was 0-6 hours (aOR per 15-minute delay = .94; 95% CI, .89-.99; P = .05) or ASPECTS 8-10 (aOR = .98; 95% CI, .97-.99; P = .002) as opposed to when LKN-puncture time was 6-24 hours (aOR per 15-minute delay = .99; 95% CI, .97-1.00; P = .16) and ASPECTS <8 (aOR = .98; 95% CI, .93-1.03; P = .37). CONCLUSION/CONCLUSIONS:Decreased LKN-groin puncture time improves outcome particularly in those with good ASPECTS presenting within 6 hours. Strategies to decrease reperfusion times should be investigated, particularly in those in the early time window and with good ASPECTS.

Introduction: The latest recommendations by the American Heart / Stroke Association on the use of intravenous thrombolysis for acute ischemic stroke suggest caution in patients with significant burden of cerebral microbleeds (CMBs). We describe such a patient, not previously diagnosed with cerebral amyloid angiopathy, treated with intravenous thrombolysis.65 year old man with diabetes, hypertension, hyperlipidemia, CAD on low dose aspirin at home, who became confused while playing poker, developing speech changes and perseveration to questions. He was brought to the ER and his initial NIHSS score was 3. CT head did not show hemorrhage. CTA head / neck did not show extraor intracranial vessel stenoses. He was treated with IV TPA within 3 hours of onset, without worsening of his symptoms. 24-hour head CT showed multiple subcortical hemorrhagic foci in both hemispheres. Brain MRI did not show an acute stroke on DWI. Multiple bilateral acute hemorrhages in each hemisphere were noted, along with innumerable microbleeds in the cerebrum and cerebellum bilaterally. The patient was transferred to acute rehabilitation where he had a generalized seizure.
Conclusion(s): In patients with multiple microbleeds, suggestive of cerebral amyloid angiopathy (CAA), the use of intravenous thrombolysis can lead to significant hemorrhagic conversion. Unfortunately, the majority of such patients does not have an established diagnosis of CAA or microbleeds previously, and might still be acutely treated with IV tPA

Introduction: The indications for intravenous thrombolysis for acute ischemic stroke have been expanded after the publication of the NINDS trial in 1995 using ages 18 to 80 as inclusion criteria. There are multiple reports of patients older than 80 treated with intravenous thrombolysis, and we are describing one of the oldest cases treated. 107 year old woman originally from the Dominican Republic (age confirmed after reviewing original documents including her passport) with history of hypertension, hyperlipidemia, diabetes, CAD, history of stroke 10 years earlier with mild right-sided residual deficits, and mild dementia, who collapsed while in the bathroom and was found then to have left sided weakness with left facial droop. NIHSS score was 14. The patient was given IV TPA 2 hours after symptom onset. CTA showed right ICA occlusion and severe stenosis of the left ICA, without significant intracranial occlusion/stenoses, and she was not considered endovascular treatment candidate. Brain MRI showed an acute right hemispheric, posterior parietal / occipital, ischemic stroke in the right posterior MCA / PCA territory. Her left-sided deficits had improved by the next day and the patient was discharged home four days later, able to walk with a walker. She was doing well when seen 4 months later.
Conclusion(s): The expansion of the criteria for the use of intravenous thrombolysis in acute ischemic stroke has shuttered the upper age limit. In otherwise appropriate candidates no maximum age limit should exist