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Multiple Administrations of Intravenous Thrombolytic Therapy to a Stroke Mimic
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–4, 2019 Ó 2019 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
https://doi.org/10.1016/j.jemermed.2019.10.004
Clinical Communications: Adult MULTIPLE ADMINISTRATIONS OF INTRAVENOUS THROMBOLYTIC THERAPY TO A STROKE MIMIC Ava L. Liberman, MD,* Daniel Antoniello, MD,* Steven Tversky, DO,† Michael G. Fara, MD, PHD,‡ Cen Zhang, MD,§ Lindsey Gurin, MD,§ and Sara K. Rostanski, MD§ *Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, †Department of Neurology, Winthrop-University Hospital, Mineola, New York, ‡Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, and §Department of Neurology, New York University School of Medicine, New York, New York Reprint Address: Ava L. Liberman, MD, Montefiore Medical Center, Stern Stroke Center, 3316 Rochambeau Avenue, 4th Floor, Bronx, NY, 10467
, Keywords—diagnostic error; health information exchange; acute ischemic stroke; psychiatry; stroke mimic
, Abstract—Background: Patients who present emergently with focal neurological deficits concerning for acute ischemic stroke can be extremely challenging to diagnose and treat. Unnecessary administration of thrombolytics to potential stroke patients whose symptoms are not caused by an acute ischemic stroke—stroke mimics—may result in patient harm, although the overall risk of hemorrhagic complications among stroke mimics is low. Case Report: We present a case of a stroke mimic patient with underlying psychiatric disease who was treated with intravenous alteplase on four separate occasions in four different emergency departments in the same city. Although he did not suffer hemorrhagic complications, this case highlights the importance of rapid exchange of health information across institutions to improve diagnostic quality and safety. Why Should an Emergency Physician Be Aware of This?: Increased awareness of stroke mimics by emergency physicians may improve diagnostic safety for a subset of high-risk patients. Establishing rapid cross-institutional communication pathways that are integrated into provider’s workflows to convey essential patient health information has potential to improve stroke diagnostic decision-making and thus represents an important topic for health systems research in emergency medicine. Ó 2019 Elsevier Inc. All rights reserved.
INTRODUCTION Diagnostic decision-making in the emergency department (ED) among patients who present with new neurological deficits can be extremely challenging. Although the thrombolysis of stroke mimics (SM), nonvascular conditions that simulate stroke, is associated with low rates of hemorrhagic or other complications, thrombolysis may delay accurate identification of an underlying neurological or nonneurological condition (1,2). Additionally, inappropriate treatment of SM with thrombolysis can be costly (3,4). Patients with psychiatric disorders presenting with new neurological deficits may be particularly vulnerable to diagnostic error (5). Herein, we report a case of an SM patient who received thrombolysis in different EDs in a single city after presenting with symptoms of right-sided weakness on four separate occasions. Our findings highlight the importance of timely electronic health information exchange (HIE) among health care providers in the emergency setting to improve acute ischemic stroke evaluation and prevent potential patient harm (6,7).
Dr. Liberman receives research support from National Institutes of Health, United States grant K23NS107643.
RECEIVED: 21 June 2019; FINAL SUBMISSION RECEIVED: 7 October 2019; ACCEPTED: 13 October 2019 1
2
A. L. Liberman et al.
CASE REPORT A 62-year-old right-handed man with a history of coronary artery disease, hypertension, and chronic kidney disease on dual antiplatelet therapy presented to a local ED with 30 min of right-sided weakness. He described the weakness as sudden in onset and painless. On physical examination, he was afebrile, normotensive, and fully oriented without aphasia. He had moderate dysarthria and right face, arm, and leg weakness. Noncontrast head computed tomography obtained emergently showed no hemorrhage or evidence of early infarction. Alteplase was quickly administered in the ED to treat a suspected acute ischemic stroke. Subsequent magnetic resonance imaging (MRI) revealed no cerebral infarction; a small chronic hemorrhage in the right parietal lobe was noted. Magnetic resonance angiography showed mild to moderate diffuse intracranial atherosclerotic narrowing. Laboratory and cardiac evaluation, including echocardiography and interrogation of a preexisting loop recorder, were unremarkable. Neurological findings were noted to be inconsistent on subsequent evaluations. A definitive diagnosis was not made at discharge. Eighteen days later, our patient presented to a different hospital in the same city with sudden-onset right hemiparesis and, again, received alteplase acutely. Subsequent work-up revealed no acute stroke and he was discharged home. Twenty days later, our patient presented to a third city hospital reporting a transient loss of consciousness that had resolved by the time of hospital arrival. ED staff noted he was leaning toward his right with right arm weakness. He received alteplase emergently again for suspected acute ischemic stroke. He did not disclose his two recent hospitalizations. An MRI scan of the brain was negative for acute infarction. On subsequent evaluations he had right arm giveway weakness, he was able to initially provide resistance when tested by the examiner but then suddenly provided no further muscular resistance. It was noted that he had slow right finger taps when formally evaluated, however, he used his right hand normally to pick up objects when informally observed. While at a rehabilitation center a few days after thrombolysis, he complained of abnormal right arm movements. Continuous electroencephalographic monitoring for 48 h was unremarkable. He endorsed that ‘‘tPA [tissue plasminogen activator] worked wonders’’ and reported his symptoms had ‘‘immediately improved’’ after receiving the drug. Four weeks later, he presented to a fourth city hospital with a complaint of sudden-onset right-sided weakness. Examination showed dysarthria and mild right hemiparesis. He reported a stroke in the distant past without residual deficits. He was again treated with alteplase in the ED.
Several hours later, when asked to move his right arm he did so slowly but offered a quick, strong handshake when greeting team members. A Hoover’s sign, absent right hip extension with contralateral (left) hip flexion against resistance, concerning for nonphysiological weakness, was present. No acute or subacute infarcts were seen on MRI, and his chronic parietal hemorrhage was unchanged (Figure 1). Using an electronic health records vendor HIE network, documentation of a prior hospitalization a few years earlier where the diagnosis of functional neurological disorder had been entertained, was found. Eventually, after our patient provided written consent for medical record sharing, the aforementioned three recent hospitalizations where an ischemic stroke was initially suspected were identified by the treatment team via requesting facsimiles of the patient’s health records from each hospital. The patient was extremely vague when asked about his prior hospitalizations and declined to clarify why he had presented to different hospitals in the same city. His affect, mood, thought processes, and thought content were normal. He reported adherence to his prescribed medications, denied any recent life stressors, and refused to be seen by Psychiatry in the inpatient setting. After this fourth hospitalization, he has missed subsequent outpatient clinic appointments. DISCUSSION Our case of an SM patient receiving alteplase four times in < 3 months is particularly complex. Although our patient had a number of cerebrovascular risk factors that raise the pretest probability for stroke, his multiple presentations without radiographic evidence of cerebral infarction on any occasion should likely have prompted a broadening of the differential diagnosis to include psychiatric illnesses at an earlier point in his treatment course (8,9). Our patient demonstrated positive examination findings (e.g., giveway weakness and Hoover’s sign) that could be consistent with the diagnosis of functional neurological symptom disorder, factitious disorder, or malingering. His repeated seeking of treatment at unaffiliated hospitals in different parts of the city, disclosure of information in a selective and misleading way, eager agreement to medical treatment, atypical illness course, opposition to psychiatric assessment, and lack of obvious external rewards for his behavior are suggestive of factitious disorder in which there is conscious production of symptoms for unconscious (primary) gain (10). Although factitious disorder can be difficult to identify, especially in an emergency setting, missing the diagnosis can put patients at risk of harm from unnecessary medical interventions while obscuring potentially treatable underlying psychiatric comorbidities.
Multiple Administrations of Intravenous Thrombolytic Therapy to a Stroke Mimic
3
Figure 1. Magnetic resonance imaging scan of the brain obtained after alteplase administration showing (A) absence of acute or subacute infarction on fluid-attenuated inversion recovery sequence and (B) a small chronic hemorrhage within the right parietal lobe on gradient echo sequence.
Poor communication between unaffiliated medical centers is largely to blame for multiple administrations of thrombolysis in this case. None of the first three EDs where our patient received alteplase participated in an electronic HIE with the fourth center; however, use of an electronic health records vendor-run HIE did provide key information that led the treatment team to request the patient’s health records from surrounding city hospitals. Failure to expand HIE has been noted in the United States by the Office of National Coordinator for Health Information Technology (ONC) and others (11). In 2015, only one-fifth of hospitals engaged in all four of the core domains of HIE as articulated by the ONC: finding, sending, receiving, and using data (12). Even when HIE exists, there may be barriers to its utilization. In an ED-based study of use of the Care Everywhere Network by Epic (Verona, WI), an HIE initiative by an EHR vendor, providers queried Care Everywhere in only 1.5% of eligible cases during a 6month period (13). State and federal health information privacy laws are frequently cited by providers and institutions as obstacles to HIE utilization and expansion despite the fact that the Health Insurance Portability and Accountability Act presents no obstacle to electronically sharing protected heath information for treatment purposes (11). This act also does not hold providers who properly disclose patient health information liable for privacy breaches by the recipients (11). We suspect that in our patient’s case, his underlying psychiatric disorder, the need for information exchange via facsimile, and providers’ lack of knowledge of the Health Insurance Portability and Accountability Act, which certainly applies in the case of acute thrombolysis decisionmaking, impeded communication across institutions. Additionally, the time-sensitive nature of acute ischemic
stroke thrombolysis can present a significant barrier to detailed review of a patient’s past medical history. Strategies to facilitate rapid, electronic HIE utilization in the ED, which may include clarifying where legal constraints do and do not exist, are broadly needed in the United States (11). Balancing the often-competing need for diagnostic certainty and rapid administration of thrombolytics to suspected acute ischemic stroke patients can be challenging (8). Whether there is a subset of suspected stroke patients without true neurological disease who are at risk of repeated alteplase administration, as seen in our case, requires future study (14). The overall frequency of SM with underlying psychiatric illness is not well known. In a recent study, acute ischemic stroke patients with a history of psychiatric illness were actually less likely to be treated with alteplase as compared to stroke patients without psychiatric illness (15). Failure to recognize and treat acute ischemic stroke patients, including those with psychiatric comorbidities, likely results in more societal harm than does the overtreatment of stroke mimics (4). Improving HIE utilization in the ED when rapid decisions must be made should enhance overall care quality and may reduce rates of SM thrombolysis (6,13).
WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Increased awareness of stroke mimics and encouraging the expansion and implementation of electronic HIE to inform time-sensitive treatments among unaffiliated EDs may improve diagnostic safety for a subset of high-risk patients.
4
A. L. Liberman et al.
REFERENCES 1. Tsivgoulis G, Zand R, Katsanos AH, et al. Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis. Stroke 2015;46:1281–7. 2. Burton TM, Luby M, Nadareishvili Z, et al. Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes. Neurology 2017;89:343–8. 3. Goyal N, Male S, Al Wafai A, Bellamkonda S, Zand R. Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment. J Stroke Cerebrovasc Dis 2015;24:828–33. 4. Liberman AL, Choi HJ, French DD, Prabhakaran S. Is the costeffectiveness of stroke thrombolysis affected by proportion of stroke mimics? Stroke 2019;50:463–8. 5. National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in healthcare. Washington, DC: The National Academies Press; 2015. 6. Usher M, Sahni N, Herrigel D, et al. Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. J Gen Intern Med 2018;33:1447–53. 7. Schiff GD. Minimizing diagnostic error: the importance of followup and feedback. Am J Med 2008;121(5 suppl):S38–42. 8. Saver JL, Barsan WG. Swift or sure? The acceptable rate of neurovascular mimics among IV tPA-treated patients. Neurology 2010; 74:1336–7.
9. Gargalas S, Weeks R, Khan-Bourne N, et al. Incidence and outcome of functional stroke mimics admitted to a hyperacute stroke unit. J Neurol Neurosurg Psychiatry 2017;88:2–6. 10. Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet 2014; 383:1422–32. 11. Mello MM, Adler-Milstein J, Ding KL, Savage L. Legal barriers to the growth of health information exchange-boulders or pebbles? Milbank Q 2018;96:110–43. 12. Office of the National Coordinator for Health Information Technology. Report to Congress on Health IT Progress: Examining the HITECH Era and the Future of Health IT. Washington, DC: Department of Health and Human Services; 2016. Available at: https://www.healthit.gov/sites/default/files/2016_report_to_congr ess_on_healthit_progress.pdf. Accessed September 24, 2019. 13. Winden TJ, Boland LL, Frey NG, Satterlee PA, Hokanson JS. Care everywhere, a point-to-point HIE tool: utilization and impact on patient care in the ED. Appl Clin Inform 2014;5: 388–401. 14. Sequeria AJ, Fara MG, Lewis A. Ethical challenges in acute evaluation of suspected psychogenic stroke mimics. J Clin Ethics 2018; 29:185–90. 15. Bongiorno DM, Daumit GL, Gottesman RF, Faigle R. Comorbid psychiatric disease is associated with lower rates of thrombolysis in ischemic stroke. Stroke 2018;49: 738–40.
https://doi.org/10.1016/j.jemermed.2019.10.004
Clinical Communications: Adult MULTIPLE ADMINISTRATIONS OF INTRAVENOUS THROMBOLYTIC THERAPY TO A STROKE MIMIC Ava L. Liberman, MD,* Daniel Antoniello, MD,* Steven Tversky, DO,† Michael G. Fara, MD, PHD,‡ Cen Zhang, MD,§ Lindsey Gurin, MD,§ and Sara K. Rostanski, MD§ *Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, †Department of Neurology, Winthrop-University Hospital, Mineola, New York, ‡Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, and §Department of Neurology, New York University School of Medicine, New York, New York Reprint Address: Ava L. Liberman, MD, Montefiore Medical Center, Stern Stroke Center, 3316 Rochambeau Avenue, 4th Floor, Bronx, NY, 10467
, Keywords—diagnostic error; health information exchange; acute ischemic stroke; psychiatry; stroke mimic
, Abstract—Background: Patients who present emergently with focal neurological deficits concerning for acute ischemic stroke can be extremely challenging to diagnose and treat. Unnecessary administration of thrombolytics to potential stroke patients whose symptoms are not caused by an acute ischemic stroke—stroke mimics—may result in patient harm, although the overall risk of hemorrhagic complications among stroke mimics is low. Case Report: We present a case of a stroke mimic patient with underlying psychiatric disease who was treated with intravenous alteplase on four separate occasions in four different emergency departments in the same city. Although he did not suffer hemorrhagic complications, this case highlights the importance of rapid exchange of health information across institutions to improve diagnostic quality and safety. Why Should an Emergency Physician Be Aware of This?: Increased awareness of stroke mimics by emergency physicians may improve diagnostic safety for a subset of high-risk patients. Establishing rapid cross-institutional communication pathways that are integrated into provider’s workflows to convey essential patient health information has potential to improve stroke diagnostic decision-making and thus represents an important topic for health systems research in emergency medicine. Ó 2019 Elsevier Inc. All rights reserved.
INTRODUCTION Diagnostic decision-making in the emergency department (ED) among patients who present with new neurological deficits can be extremely challenging. Although the thrombolysis of stroke mimics (SM), nonvascular conditions that simulate stroke, is associated with low rates of hemorrhagic or other complications, thrombolysis may delay accurate identification of an underlying neurological or nonneurological condition (1,2). Additionally, inappropriate treatment of SM with thrombolysis can be costly (3,4). Patients with psychiatric disorders presenting with new neurological deficits may be particularly vulnerable to diagnostic error (5). Herein, we report a case of an SM patient who received thrombolysis in different EDs in a single city after presenting with symptoms of right-sided weakness on four separate occasions. Our findings highlight the importance of timely electronic health information exchange (HIE) among health care providers in the emergency setting to improve acute ischemic stroke evaluation and prevent potential patient harm (6,7).
Dr. Liberman receives research support from National Institutes of Health, United States grant K23NS107643.
RECEIVED: 21 June 2019; FINAL SUBMISSION RECEIVED: 7 October 2019; ACCEPTED: 13 October 2019 1
2
A. L. Liberman et al.
CASE REPORT A 62-year-old right-handed man with a history of coronary artery disease, hypertension, and chronic kidney disease on dual antiplatelet therapy presented to a local ED with 30 min of right-sided weakness. He described the weakness as sudden in onset and painless. On physical examination, he was afebrile, normotensive, and fully oriented without aphasia. He had moderate dysarthria and right face, arm, and leg weakness. Noncontrast head computed tomography obtained emergently showed no hemorrhage or evidence of early infarction. Alteplase was quickly administered in the ED to treat a suspected acute ischemic stroke. Subsequent magnetic resonance imaging (MRI) revealed no cerebral infarction; a small chronic hemorrhage in the right parietal lobe was noted. Magnetic resonance angiography showed mild to moderate diffuse intracranial atherosclerotic narrowing. Laboratory and cardiac evaluation, including echocardiography and interrogation of a preexisting loop recorder, were unremarkable. Neurological findings were noted to be inconsistent on subsequent evaluations. A definitive diagnosis was not made at discharge. Eighteen days later, our patient presented to a different hospital in the same city with sudden-onset right hemiparesis and, again, received alteplase acutely. Subsequent work-up revealed no acute stroke and he was discharged home. Twenty days later, our patient presented to a third city hospital reporting a transient loss of consciousness that had resolved by the time of hospital arrival. ED staff noted he was leaning toward his right with right arm weakness. He received alteplase emergently again for suspected acute ischemic stroke. He did not disclose his two recent hospitalizations. An MRI scan of the brain was negative for acute infarction. On subsequent evaluations he had right arm giveway weakness, he was able to initially provide resistance when tested by the examiner but then suddenly provided no further muscular resistance. It was noted that he had slow right finger taps when formally evaluated, however, he used his right hand normally to pick up objects when informally observed. While at a rehabilitation center a few days after thrombolysis, he complained of abnormal right arm movements. Continuous electroencephalographic monitoring for 48 h was unremarkable. He endorsed that ‘‘tPA [tissue plasminogen activator] worked wonders’’ and reported his symptoms had ‘‘immediately improved’’ after receiving the drug. Four weeks later, he presented to a fourth city hospital with a complaint of sudden-onset right-sided weakness. Examination showed dysarthria and mild right hemiparesis. He reported a stroke in the distant past without residual deficits. He was again treated with alteplase in the ED.
Several hours later, when asked to move his right arm he did so slowly but offered a quick, strong handshake when greeting team members. A Hoover’s sign, absent right hip extension with contralateral (left) hip flexion against resistance, concerning for nonphysiological weakness, was present. No acute or subacute infarcts were seen on MRI, and his chronic parietal hemorrhage was unchanged (Figure 1). Using an electronic health records vendor HIE network, documentation of a prior hospitalization a few years earlier where the diagnosis of functional neurological disorder had been entertained, was found. Eventually, after our patient provided written consent for medical record sharing, the aforementioned three recent hospitalizations where an ischemic stroke was initially suspected were identified by the treatment team via requesting facsimiles of the patient’s health records from each hospital. The patient was extremely vague when asked about his prior hospitalizations and declined to clarify why he had presented to different hospitals in the same city. His affect, mood, thought processes, and thought content were normal. He reported adherence to his prescribed medications, denied any recent life stressors, and refused to be seen by Psychiatry in the inpatient setting. After this fourth hospitalization, he has missed subsequent outpatient clinic appointments. DISCUSSION Our case of an SM patient receiving alteplase four times in < 3 months is particularly complex. Although our patient had a number of cerebrovascular risk factors that raise the pretest probability for stroke, his multiple presentations without radiographic evidence of cerebral infarction on any occasion should likely have prompted a broadening of the differential diagnosis to include psychiatric illnesses at an earlier point in his treatment course (8,9). Our patient demonstrated positive examination findings (e.g., giveway weakness and Hoover’s sign) that could be consistent with the diagnosis of functional neurological symptom disorder, factitious disorder, or malingering. His repeated seeking of treatment at unaffiliated hospitals in different parts of the city, disclosure of information in a selective and misleading way, eager agreement to medical treatment, atypical illness course, opposition to psychiatric assessment, and lack of obvious external rewards for his behavior are suggestive of factitious disorder in which there is conscious production of symptoms for unconscious (primary) gain (10). Although factitious disorder can be difficult to identify, especially in an emergency setting, missing the diagnosis can put patients at risk of harm from unnecessary medical interventions while obscuring potentially treatable underlying psychiatric comorbidities.
Multiple Administrations of Intravenous Thrombolytic Therapy to a Stroke Mimic
3
Figure 1. Magnetic resonance imaging scan of the brain obtained after alteplase administration showing (A) absence of acute or subacute infarction on fluid-attenuated inversion recovery sequence and (B) a small chronic hemorrhage within the right parietal lobe on gradient echo sequence.
Poor communication between unaffiliated medical centers is largely to blame for multiple administrations of thrombolysis in this case. None of the first three EDs where our patient received alteplase participated in an electronic HIE with the fourth center; however, use of an electronic health records vendor-run HIE did provide key information that led the treatment team to request the patient’s health records from surrounding city hospitals. Failure to expand HIE has been noted in the United States by the Office of National Coordinator for Health Information Technology (ONC) and others (11). In 2015, only one-fifth of hospitals engaged in all four of the core domains of HIE as articulated by the ONC: finding, sending, receiving, and using data (12). Even when HIE exists, there may be barriers to its utilization. In an ED-based study of use of the Care Everywhere Network by Epic (Verona, WI), an HIE initiative by an EHR vendor, providers queried Care Everywhere in only 1.5% of eligible cases during a 6month period (13). State and federal health information privacy laws are frequently cited by providers and institutions as obstacles to HIE utilization and expansion despite the fact that the Health Insurance Portability and Accountability Act presents no obstacle to electronically sharing protected heath information for treatment purposes (11). This act also does not hold providers who properly disclose patient health information liable for privacy breaches by the recipients (11). We suspect that in our patient’s case, his underlying psychiatric disorder, the need for information exchange via facsimile, and providers’ lack of knowledge of the Health Insurance Portability and Accountability Act, which certainly applies in the case of acute thrombolysis decisionmaking, impeded communication across institutions. Additionally, the time-sensitive nature of acute ischemic
stroke thrombolysis can present a significant barrier to detailed review of a patient’s past medical history. Strategies to facilitate rapid, electronic HIE utilization in the ED, which may include clarifying where legal constraints do and do not exist, are broadly needed in the United States (11). Balancing the often-competing need for diagnostic certainty and rapid administration of thrombolytics to suspected acute ischemic stroke patients can be challenging (8). Whether there is a subset of suspected stroke patients without true neurological disease who are at risk of repeated alteplase administration, as seen in our case, requires future study (14). The overall frequency of SM with underlying psychiatric illness is not well known. In a recent study, acute ischemic stroke patients with a history of psychiatric illness were actually less likely to be treated with alteplase as compared to stroke patients without psychiatric illness (15). Failure to recognize and treat acute ischemic stroke patients, including those with psychiatric comorbidities, likely results in more societal harm than does the overtreatment of stroke mimics (4). Improving HIE utilization in the ED when rapid decisions must be made should enhance overall care quality and may reduce rates of SM thrombolysis (6,13).
WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Increased awareness of stroke mimics and encouraging the expansion and implementation of electronic HIE to inform time-sensitive treatments among unaffiliated EDs may improve diagnostic safety for a subset of high-risk patients.
4
A. L. Liberman et al.
REFERENCES 1. Tsivgoulis G, Zand R, Katsanos AH, et al. Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis. Stroke 2015;46:1281–7. 2. Burton TM, Luby M, Nadareishvili Z, et al. Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes. Neurology 2017;89:343–8. 3. Goyal N, Male S, Al Wafai A, Bellamkonda S, Zand R. Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment. J Stroke Cerebrovasc Dis 2015;24:828–33. 4. Liberman AL, Choi HJ, French DD, Prabhakaran S. Is the costeffectiveness of stroke thrombolysis affected by proportion of stroke mimics? Stroke 2019;50:463–8. 5. National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in healthcare. Washington, DC: The National Academies Press; 2015. 6. Usher M, Sahni N, Herrigel D, et al. Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. J Gen Intern Med 2018;33:1447–53. 7. Schiff GD. Minimizing diagnostic error: the importance of followup and feedback. Am J Med 2008;121(5 suppl):S38–42. 8. Saver JL, Barsan WG. Swift or sure? The acceptable rate of neurovascular mimics among IV tPA-treated patients. Neurology 2010; 74:1336–7.
9. Gargalas S, Weeks R, Khan-Bourne N, et al. Incidence and outcome of functional stroke mimics admitted to a hyperacute stroke unit. J Neurol Neurosurg Psychiatry 2017;88:2–6. 10. Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical assessment and management. Lancet 2014; 383:1422–32. 11. Mello MM, Adler-Milstein J, Ding KL, Savage L. Legal barriers to the growth of health information exchange-boulders or pebbles? Milbank Q 2018;96:110–43. 12. Office of the National Coordinator for Health Information Technology. Report to Congress on Health IT Progress: Examining the HITECH Era and the Future of Health IT. Washington, DC: Department of Health and Human Services; 2016. Available at: https://www.healthit.gov/sites/default/files/2016_report_to_congr ess_on_healthit_progress.pdf. Accessed September 24, 2019. 13. Winden TJ, Boland LL, Frey NG, Satterlee PA, Hokanson JS. Care everywhere, a point-to-point HIE tool: utilization and impact on patient care in the ED. Appl Clin Inform 2014;5: 388–401. 14. Sequeria AJ, Fara MG, Lewis A. Ethical challenges in acute evaluation of suspected psychogenic stroke mimics. J Clin Ethics 2018; 29:185–90. 15. Bongiorno DM, Daumit GL, Gottesman RF, Faigle R. Comorbid psychiatric disease is associated with lower rates of thrombolysis in ischemic stroke. Stroke 2018;49: 738–40.