ISC 2009: Misdiagnosis of Young Stroke Patients Not Uncommon

Caroline Cassels

February 19, 2009

February 19, 2009 (San Diego, California) — It is not uncommon for young adults with stroke to be misdiagnosed during initial presentation to the emergency department, particularly if they experience an infarct in their posterior circulation.

New research presented here at the American Stroke Association International Stroke Conference 2009 shows an overall misdiagnosis rate of 14% among adults under the age of 50 years.

"In these individuals, we also found there was a strong trend among the very youngest patients — those under age 35 — to have an even greater chance of misdiagnosis," principal investigator Seemant Chaturvedi, MD, from Wayne State University, in Detroit, Michigan, told Medscape Neurology.

Dr. Chaturvedi said his own anecdotal experience and that of some of his colleagues led them to look into the issue of misdiagnosis in young stroke patients.

"I think we've all seen young patients who, even though they have presented to the emergency department early after symptom onset, do not receive the proper diagnosis. When that happens, patients are deprived of the opportunity to receive [tissue plasminogen activator] tPA or interventional stroke therapy, so we decided to look at this issue in a more systematic way," he said.

Inner-Ear Disorder Diagnosed in 50%

The researchers reviewed data on 57 patients aged 16 to 50 years enrolled since 2001 in the Young Stroke Registry at the Comprehensive Stroke Center at Wayne State University.

With an average age of 38 years, 8 patients — 4 males and 4 females — were misdiagnosed with conditions including alcohol intoxication, migraine, vertigo, and inner-ear disorder.

Of these, half were diagnosed with an inner-ear disorder, including labyrinthitis or peripheral vertigo, and subsequently ended up being diagnosed with stroke in the brain stem or cerebellum. One 18-year-old patient diagnosed with alcohol intoxication also ended up with a diagnosis of posterior cerebral artery stroke.

Of the misdiagnosed cases, 7 of the 8 presented within 3 hours to the emergency department. Of these, said Dr. Chaturvedi, 3 would have been considered good candidates for thrombolysis.

A Diagnostic Challenge

Diagnosing posterior stroke can be challenging, said Dr. Chaturvedi.

"There are a number of neural pathways in the brain stem that can affect different functions, including strength, coordination, speech, eye movements, hearing, and swallowing. So to a nonspecialist, it can be challenging to tease out which of these are serious and which are benign," he said.

Nevertheless, he added, the presenting signs and symptoms in these misdiagnosed patients were not atypical.

"It may be that physicians are just not expecting stroke [in these young patients]. A lot of the presentations were classic for stroke, but for whatever reason, they just weren't recognized as such," he said.

Dr. Chaturvedi said the study highlights the need for efforts to increase awareness among the public and clinicians that stroke can occur in young people. He estimated that in the United States there are approximately 10,000 to 15,000 strokes in individuals under the age of 45 years annually.

"I think I would recommend that doctors consider a diagnosis of stroke in patients who present with acute neurologic deficits, regardless of age. It is particularly important in patients who present with dizziness to evaluate patients' gait, speech, and eye movements before concluding their condition is benign."

Dr. Chaturvedi said his future research will examine potential differences between misdiagnosis rates in designated and undesignated stroke centers.

International Stroke Conference 2009: Abstract 33. Presented February 18, 2009.

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