Difficulty in Posterior Stroke Diagnosis Delays Treatment

Daniel M. Keller, PhD

November 13, 2014

ISTANBUL, Turkey — Acute posterior circulation ischemic strokes are more difficult to diagnose in the emergency department (ED) than anterior circulation strokes, which leads to longer times before a neurologist is called in and delays in definitive treatment, a recent study shows.

M.R. Sivakumar, MD, DM, PhD, from the Cerebrovascular and Vasculitis Research Foundation in Chennai, India, noted that symptoms of posterior circulation strokes may be subtle or underappreciated. He therefore performed a prospective cross-sectional study to gauge the times required for patient assessment, consultation, diagnosis, and treatment.

He presented the results here during a poster presentation at the 9th World Stroke Congress (WSC).

The study, which ran from June 2000 to December 2013, included 72 patients with posterior circulation strokes among 479 consecutive patients presenting to a tertiary care center and given intravenous tissue plasminogen activator (tPA) within 4.5 hours of symptom onset. The researchers compared demographic, clinical, and treatment variables between the patients with posterior and those with anterior circulation strokes.

The median baseline National Institutes of Health Stroke Scale score was 7.4 for the patients with posterior circulation strokes. Compared with the times for anterior circulation strokes, it took longer to obtain a neurologist evaluation and longer before tPA was administered for posterior circulation strokes.

Because the neurologist-to-needle time was the same for both cohorts, the delay in door-to-needle time appears to be largely a function of the delay in getting a neurologic consult. Dr Sivakumar attributed this delay in the neurology evaluation to the presence of nausea and vomiting, which were significantly associated with a treatment delay of 15 minutes.

Patients with posterior circulation stroke did well overall, with 72% achieving a modified Rankin Scale score of 1 to 2 at 90 days. One patient with a basilar artery thrombosis died.

Table. Time to Recognition and Treatment of Posterior vs Anterior Circulation Strokes

Variable Posterior Circulation Stroke (min) Anterior Circulation Stroke (min) P Value
Time from ED physician evaluation to neurologist evaluation 35 20 <.002
Door-to-needle time 52 38 <.002
Neurologist-to-needle time 16 16 >.05

 

Didier Leys, MD, PhD, professor of neurology at the University of Lille, France, said the findings are not necessarily new but confirm that people with a posterior circulation stroke present to the hospital a bit later and that the management takes a bit longer.

"I think this is mainly due to the fact that in these strokes — you have posterior fossa strokes — for which the symptoms are not exactly the same and sometimes are a little misleading [with] diplopia and so on," he said.

He pointed out that the researchers did not distinguish between occipital strokes and posterior fossa strokes. "I think the major difference comes from posterior fossa brainstem strokes probably."

Asked why the problem of delayed diagnosis and treatment has not already been better addressed, Dr Leys replied that it is mainly because of the atypical symptoms, which do not always suggest a stroke.

"Sometimes they suggest a coma or something like this, and we take more time to make the diagnosis, and we have many more patients with a wrong diagnosis before the diagnosis of stroke is made," he told Medscape Medical News. One possibility in the differential diagnosis is a toxic event.

A solution may be to lower the threshold for considering a stroke etiology, but that has its downsides, too.

"Of course, you will detect easily these patients, but the problem is that you will be polluted by a lot of patients with other kinds of neurological disorders," he predicted. He said it is a difficult issue for emergency physicians and for stroke physicians, as well, and is present in all centers.

Dr Sivakumar and Dr Leys have disclosed no relevant financial relationships. Dr Sivakumar is managing director of GLB Hospitals, a unit of Genelab Biotechnologies Private Ltd.

9th World Stroke Congress (WSC). Abstract 30. Presented October 23, 2014.

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