- Email: [email protected]
237: Misdiagnosis of Spinal Cord Compression In the Emergency Department
Research Forum Abstracts Results: Overall, there were 181 participants (91 in the FAST group and 90 in the SUDDENS group). The average age was 22 with females comprising 52% of the sample. The SUDDENS group had a higher average change in the STAT score compared to the FAST group (p ⫽ 0.02), although the 95% confidence intervals (CI) slightly overlapped (8.92; 95% CI 7.76-10.08 STAT versus 6.67; 95% CI 5.52-7.82, respectively). When looking at the subset of questions that did not contain the word “sudden,” there was no difference between the two posters (2.38; 95% CI 2.00-2.75 in the SUDDENS group versus 2.36; 95% CI 1.99-2.74 in the FAST Group; p⫽0.94). Only 33 individuals completed the long term follow-up with no significant STAT change from baseline (p⫽0.91) between the FAST and SUDDENS group (7.80; 95% CI 4.56-11.04 versus 6.89; 95% CI 3.94-9.84, respectively). Between the initial post test and the long term follow-up survey, those viewing the FAST poster had an average decrease in their STAT score of -0.44 (95% CI -3.25-2.44) versus the SUDDENS group which had an average decrease of -1.44 (95% CI -4.04-1.15). Conclusions: Viewing a poster which contains common stroke symptoms with sudden onset results in slightly higher initial stroke knowledge acquisition in comparison to viewing a poster with the FAST mnemonic. However, this difference may be due to the repetition of the word “sudden” in the STAT, which could bias the results, as no difference was observed when looking at stroke symptom questions not containing the word “sudden.” These results suggest that future stroke education strategies could continue to use either or both messages to educate the public, although perennial public stroke knowledge gaps may indicate a need to develop new, more effective messages. Further research on the performance of these messages in populations most at risk (ie, the elderly) and those who care for them is also needed.
236
The Prognostic Value of Serum Troponin T In Acute Brain Ischemia
Stead LG, Jain A, Bellolio M, Bhagra A, Gilmore RM, Decker WW/Mayo Clinic College of Medicine, Rochester, MN
Study Objective: To determine whether early serum troponin is elevated early in the course of acute ischemic stroke (AIS), and to determine whether such elevation correlates to stroke severity, functional disability or mortality after AIS. Methods: The cohort consisted of 362 consecutive local patients who presented to the emergency department (ED) of an academic medical center between December 2001 to March 2004 with an acute ischemic stroke and had a serum troponin drawn at the time of ED presentation. A serum troponin T was obtained at the time of the ED visit and categorized as being normal (⬍0.01 ng/ml) or elevated. The serum was analyzed with the third generation electrochemiluminescent Troponin T immunoassay (Roche Diagnostics Corporation, Indianapolis, IN). Associations with survival within 365 days were summarized by calculating risk ratios (RR) and 95% confidence intervals (CI). Results: Patients with elevated troponin were significantly older (p⬍0.001). The 99 patients with elevated troponin, had a median age of 82 years (mean (SD), 80.1 (9.9)), compared to a median of 77 years (mean (SD), 72.4 (14.8)) for the 263 patients with a normal troponin. Fifty-two of the 173 females (30.0%) had an elevated troponin, compared to 47 of 189 males (24.9%), but this difference was not statistically significant (p⫽0.27). Patients with elevated serum troponin also had significantly more severe strokes as measured by the NIHSS (p⬍0.001), were more likely to have larger volumes of infarct (p⫽0.025), and were more likely to have a history of coronary artery disease, congestive heart failure, atrial fibrillation or diabetes (all p⬍0.05). Focusing on the first year of follow-up, patients with an elevated troponin were 2.6 times more likely to die (95% CI, 1.8-3.8; p⬍0.001) than patients with serum troponin less than 0.01 ng/ml. Conclusions: Patients with elevated serum Troponin T levels during an episode of acute ischemic stroke were more likely to die within the first year post stroke. Elevated serum troponin T correlates with higher stroke severity, larger volume of infarct and approximately two and half fold increased risk of death at one year.
237
Misdiagnosis of Spinal Cord Compression In the Emergency Department
Dugas AF, Lucas JM, Edlow JA/Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Study Objectives: Our goals were to evaluate the presenting signs and symptoms of spinal cord and cauda equina compression (SCC) and to determine the causes and incidence of emergency department (ED) misdiagnosis. Methods: We performed a retrospective chart review at an urban, tertiary care hospital with an annual ED census of approximately 50,000 visits. The institutional review board approved our study protocol and waived informed consent. We
S78 Annals of Emergency Medicine
screened all patients who were discharged from an inpatient stay over a 15-month period (April 2008-July 2009) with an International Classification of Diseases, Ninth Revision (ICD-9) code indicating spinal disease using our hospital’s electronic medical record system. Patients were included in our study if they had SCC as one of their final diagnoses upon inpatient discharge or if SCC was confirmed by magnetic resonance imaging or computed tomography myelogram during their inpatient admission, and if they had a documented visit to our ED within 30 days of their qualifying hospital admission significant for at least one subjective complaint or objective finding potentially attributable to SCC; including but not limited to back pain, neck pain, weakness, unsteadiness, motor or sensory abnormalities, or autonomic dysfunction. Cases were defined as misdiagnosed if SCC was not documented as one of the final ED diagnoses or if a patient’s workup failed to include an appropriate diagnostic study (computed tomography myelogram or magnetic resonance imaging of any spinal level) prior to ED arrival, in the ED, or immediately upon hospital admission. Trauma patients were excluded. We used descriptive statistics and statistical analysis was performed using Fisher’s exact tests for categorical variables and unpaired, two-tailed t-tests for continuous variables. Values are reported as total counts and percentages or means ⫾ standard deviations, as appropriate. Results: We reviewed 1231 charts, and 81 patients met inclusion criteria. SCC was misdiagnosed in 18 out of 81 [22% (95% confidence interval: 14.5%-32.5%)] patients. The misdiagnosed and correctly diagnosed groups were statistically similar in terms of mean age (65 ⫾10 years versus 60 ⫾ 17 years), female sex (56% versus 49%), SCC location (cervical: 61% versus 46%, thoracic: 11% versus 24%, lumbar: 22% versus 27%, and multiple sites: 6% versus 3%), SCC cause (disc herniation: 67% versus 60%, tumor: 17% versus 19%, abscess: 17% versus 8%, hematoma: 0% versus 8%, ossification of the posterior longitudinal ligament: 0% versus 3%, tuberculous spondylitis: 0% versus 2%), respectively. Time to diagnosis was significantly longer in those misdiagnosed compared to those correctly diagnosed (63 ⫾40 hours versus 10 ⫾10 hours, p⬍0.0001), but outcomes were not statistically different. Misdiagnosed patients were less likely than correctly diagnosed patients to have initial motor or sensory deficits (39% versus 62%, p⫽0.02). In addition, 17% of misdiagnosed patients presented with impaired gait as their only neurologic finding, compared to 0% of those correctly diagnosed (p⫽ 0.001). Conclusion: ED misdiagnosis of SCC is common. Increased awareness of ambulatory dysfunction as a possible early sign of SCC, with or without other neurologic findings, may improve diagnostic accuracy. Additional research is needed to further investigate the misdiagnosis of SCC.
238
Do Intra-Cranial and Neck Vessel Abnormalities Influence Cerebral Blood Flow Parameters In Ischemic Areas of Acute Stroke Patients?
Jain M, Jain A, Yerragondu N, Jahromi BB, Stead LG/University of Rochester, Rochester, NY; mayo clinic, rochester, MN
Study Objectives: To quantify differences in physiological cerebral blood flow parameters (mean transit time, cerebral blood volume, cerebral blood flow, area affected) between acute ischemic stroke patients with presence of any kind of intracranial vessel abnormalities, and those with neck vessel abnormalities. Methods: Prospective registry of all patients with stroke presenting to the ED of an academic tertiary care center, undergoing a CT perfusion scan. CT angiogram neck and head of patients were reviewed to understand which of these patients had any abnormalities in their neck vasculature (carotids, vertebrals and basilar arteries) and intra-cranial vasculature. CT perfusion scans of patients were also reviewed, to analyze, mean transit time (MTT), cerebral blood volume (CBV), cerebral blood flow (CBF) and size of the ischemic area of interest. Ischemic areas were defined as any area that had significant prolongation in the mean transit time of blood flow. Penumbra was identified from this area as the region with relative preservation of cerebral blood volume. Individual values of MTT, CBV and CBF were also noted in both these areas for each patient. Results: Of the total 74 patients with acute ischemic stroke, 24% had abnormalities detected in the intra-cranial vasculature, 20% had neck vessel abnormalities, and 29% had abnormalities in both systems. Patients with only abnormalities in the intra-cranial vasculature had significantly higher areas of blood flow compromise (median 61 sq cm, IQR 6.9 to 91.5 sq cm) when compared to patients with neck vessel abnormalities (median 6.6 sq cm, IQR 0 to 47.2 sq cm; p⫽0.023). Similarly penumbric area was also higher for patients with intra-cranial vessel abnormalities (median 44.8 sq cm, IQR 5.4 to 86.2 sq cm) when compared to patients with neck vasculature defects (median 4.3 sq cm, IQR 0 to 46.5
Volume , . : September
236
The Prognostic Value of Serum Troponin T In Acute Brain Ischemia
Stead LG, Jain A, Bellolio M, Bhagra A, Gilmore RM, Decker WW/Mayo Clinic College of Medicine, Rochester, MN
Study Objective: To determine whether early serum troponin is elevated early in the course of acute ischemic stroke (AIS), and to determine whether such elevation correlates to stroke severity, functional disability or mortality after AIS. Methods: The cohort consisted of 362 consecutive local patients who presented to the emergency department (ED) of an academic medical center between December 2001 to March 2004 with an acute ischemic stroke and had a serum troponin drawn at the time of ED presentation. A serum troponin T was obtained at the time of the ED visit and categorized as being normal (⬍0.01 ng/ml) or elevated. The serum was analyzed with the third generation electrochemiluminescent Troponin T immunoassay (Roche Diagnostics Corporation, Indianapolis, IN). Associations with survival within 365 days were summarized by calculating risk ratios (RR) and 95% confidence intervals (CI). Results: Patients with elevated troponin were significantly older (p⬍0.001). The 99 patients with elevated troponin, had a median age of 82 years (mean (SD), 80.1 (9.9)), compared to a median of 77 years (mean (SD), 72.4 (14.8)) for the 263 patients with a normal troponin. Fifty-two of the 173 females (30.0%) had an elevated troponin, compared to 47 of 189 males (24.9%), but this difference was not statistically significant (p⫽0.27). Patients with elevated serum troponin also had significantly more severe strokes as measured by the NIHSS (p⬍0.001), were more likely to have larger volumes of infarct (p⫽0.025), and were more likely to have a history of coronary artery disease, congestive heart failure, atrial fibrillation or diabetes (all p⬍0.05). Focusing on the first year of follow-up, patients with an elevated troponin were 2.6 times more likely to die (95% CI, 1.8-3.8; p⬍0.001) than patients with serum troponin less than 0.01 ng/ml. Conclusions: Patients with elevated serum Troponin T levels during an episode of acute ischemic stroke were more likely to die within the first year post stroke. Elevated serum troponin T correlates with higher stroke severity, larger volume of infarct and approximately two and half fold increased risk of death at one year.
237
Misdiagnosis of Spinal Cord Compression In the Emergency Department
Dugas AF, Lucas JM, Edlow JA/Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Study Objectives: Our goals were to evaluate the presenting signs and symptoms of spinal cord and cauda equina compression (SCC) and to determine the causes and incidence of emergency department (ED) misdiagnosis. Methods: We performed a retrospective chart review at an urban, tertiary care hospital with an annual ED census of approximately 50,000 visits. The institutional review board approved our study protocol and waived informed consent. We
S78 Annals of Emergency Medicine
screened all patients who were discharged from an inpatient stay over a 15-month period (April 2008-July 2009) with an International Classification of Diseases, Ninth Revision (ICD-9) code indicating spinal disease using our hospital’s electronic medical record system. Patients were included in our study if they had SCC as one of their final diagnoses upon inpatient discharge or if SCC was confirmed by magnetic resonance imaging or computed tomography myelogram during their inpatient admission, and if they had a documented visit to our ED within 30 days of their qualifying hospital admission significant for at least one subjective complaint or objective finding potentially attributable to SCC; including but not limited to back pain, neck pain, weakness, unsteadiness, motor or sensory abnormalities, or autonomic dysfunction. Cases were defined as misdiagnosed if SCC was not documented as one of the final ED diagnoses or if a patient’s workup failed to include an appropriate diagnostic study (computed tomography myelogram or magnetic resonance imaging of any spinal level) prior to ED arrival, in the ED, or immediately upon hospital admission. Trauma patients were excluded. We used descriptive statistics and statistical analysis was performed using Fisher’s exact tests for categorical variables and unpaired, two-tailed t-tests for continuous variables. Values are reported as total counts and percentages or means ⫾ standard deviations, as appropriate. Results: We reviewed 1231 charts, and 81 patients met inclusion criteria. SCC was misdiagnosed in 18 out of 81 [22% (95% confidence interval: 14.5%-32.5%)] patients. The misdiagnosed and correctly diagnosed groups were statistically similar in terms of mean age (65 ⫾10 years versus 60 ⫾ 17 years), female sex (56% versus 49%), SCC location (cervical: 61% versus 46%, thoracic: 11% versus 24%, lumbar: 22% versus 27%, and multiple sites: 6% versus 3%), SCC cause (disc herniation: 67% versus 60%, tumor: 17% versus 19%, abscess: 17% versus 8%, hematoma: 0% versus 8%, ossification of the posterior longitudinal ligament: 0% versus 3%, tuberculous spondylitis: 0% versus 2%), respectively. Time to diagnosis was significantly longer in those misdiagnosed compared to those correctly diagnosed (63 ⫾40 hours versus 10 ⫾10 hours, p⬍0.0001), but outcomes were not statistically different. Misdiagnosed patients were less likely than correctly diagnosed patients to have initial motor or sensory deficits (39% versus 62%, p⫽0.02). In addition, 17% of misdiagnosed patients presented with impaired gait as their only neurologic finding, compared to 0% of those correctly diagnosed (p⫽ 0.001). Conclusion: ED misdiagnosis of SCC is common. Increased awareness of ambulatory dysfunction as a possible early sign of SCC, with or without other neurologic findings, may improve diagnostic accuracy. Additional research is needed to further investigate the misdiagnosis of SCC.
238
Do Intra-Cranial and Neck Vessel Abnormalities Influence Cerebral Blood Flow Parameters In Ischemic Areas of Acute Stroke Patients?
Jain M, Jain A, Yerragondu N, Jahromi BB, Stead LG/University of Rochester, Rochester, NY; mayo clinic, rochester, MN
Study Objectives: To quantify differences in physiological cerebral blood flow parameters (mean transit time, cerebral blood volume, cerebral blood flow, area affected) between acute ischemic stroke patients with presence of any kind of intracranial vessel abnormalities, and those with neck vessel abnormalities. Methods: Prospective registry of all patients with stroke presenting to the ED of an academic tertiary care center, undergoing a CT perfusion scan. CT angiogram neck and head of patients were reviewed to understand which of these patients had any abnormalities in their neck vasculature (carotids, vertebrals and basilar arteries) and intra-cranial vasculature. CT perfusion scans of patients were also reviewed, to analyze, mean transit time (MTT), cerebral blood volume (CBV), cerebral blood flow (CBF) and size of the ischemic area of interest. Ischemic areas were defined as any area that had significant prolongation in the mean transit time of blood flow. Penumbra was identified from this area as the region with relative preservation of cerebral blood volume. Individual values of MTT, CBV and CBF were also noted in both these areas for each patient. Results: Of the total 74 patients with acute ischemic stroke, 24% had abnormalities detected in the intra-cranial vasculature, 20% had neck vessel abnormalities, and 29% had abnormalities in both systems. Patients with only abnormalities in the intra-cranial vasculature had significantly higher areas of blood flow compromise (median 61 sq cm, IQR 6.9 to 91.5 sq cm) when compared to patients with neck vessel abnormalities (median 6.6 sq cm, IQR 0 to 47.2 sq cm; p⫽0.023). Similarly penumbric area was also higher for patients with intra-cranial vessel abnormalities (median 44.8 sq cm, IQR 5.4 to 86.2 sq cm) when compared to patients with neck vasculature defects (median 4.3 sq cm, IQR 0 to 46.5
Volume , . : September