Original Article
Stroke Mimics under the Drip-and-Ship Paradigm

https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.07.012Get rights and content

Background

Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. We hypothesized that a higher rate of stroke mimics (SM) among AIS treated in nonspecialized stroke centers that are transferred to comprehensive centers is responsible for such outcomes.

Methods

Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over 1 academic year (July 1, 2011 to June 30, 2012). Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge disposition was collected. We identified those patients who were treated at a facility and then transferred to the tertiary center (ie, drip-and-ship paradigm). In addition to comparative and adjusted analysis to identify predictors for SM, a stratified analysis by the drip-and-ship status was performed.

Results

One hundred twenty patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = .0003) and more likely to harbor psychiatric diagnoses (45% versus 9%; P ≤ .0001). Eighteen of 20 SM patients (90%) had the drip-and-ship treatment paradigm compared with 65% of those with AIS (P = .02). None of the SM had hemorrhagic complications, and all were discharged to home. Predictors of SM on adjusted analysis included the drip-and-ship paradigm (odds ratio [OR] 12.8, 95% confidence interval [CI] 1.78, 92.1) and history of any psychiatric illness (OR 12.08; 95% CI 3.14, 46.4). Eighteen of 83 drip-and-ship patients (21.7%) were diagnosed with SM compared with 2 of 37 patients (5.4%) presented directly to the hub hospital (P = .02).

Conclusion

The drip-and-ship paradigm and any psychiatric history predict the diagnosis of SM. None of the SM had thrombolysis-related complications, and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment for AIS.

Introduction

Stroke Mimics (SM) are group of conditions that present in a manner similar to acute ischemic stroke (AIS); the most common of which are conversion disorder, migraine, seizures, and Bell's palsy.1, 2 The rates of SM among all AIS or “brain attacks” had reached as high as 31%3, 4; similar high rates were found among patients with transient ischemic attack.5 The clinical presentations are often difficult to distinguish from genuine ischemic syndromes especially in emergency settings. These patients are not infrequently encountered within the window for thrombolytic therapy, and hence, they pose a clinical challenge. The rates of thrombolysis given for SM varied between 1.4% and 15.5% among all treated patients.1, 6, 7, 8, 9 There is evidence to suggest that thrombolysis is safer in this population.7, 10 In 2005, Recognition of Stroke in the Emergency Room Study attempted to come up with a stroke recognition instrument based on the clinical history and physical signs.11 Despite the high sensitivity, specificity, and predictive values, Recognition of Stroke in the Emergency Room Scale acquired little utilization in clinical practice especially in the United States where most centers adopt the simpler face arm speech test screening module.12 These screening tests frequently overlook the SM especially in less experienced centers.

The “drip-and-ship” paradigm has continued to gain popularity over the recent years especially with recent studies showing a similar safety profile when patients are treated within the spoke and hub hospitals compared with regional stroke centers.13, 14 This practice model has increased the utilization of thrombolytic therapy.15 Moreover, outcome studies suggested a comparable and perhaps superior safety and efficacy of thrombolysis if administered within the drip-and-ship paradigm.16 Our personal observations suggested a higher rate of SM among patients who were evaluated by spoke hospitals within our stroke network and treated with the drip-and-ship paradigm. In this study, we hypothesize that there is a greater likelihood of SM among patients undergoing thrombolytic therapy for AIS in the drip-and-ship paradigm.

Section snippets

Methods

A retrospective review of consecutive thrombolysis-treated patients admitted to a single comprehensive stroke center (St Louis University hospital) during 1 academic year (July 1, 2011 to June 30, 2012) was conducted. St Louis University hospital also serves as the main hub for the Mid-America Stroke Network. The network is a collaborative system of hospitals that work together to deliver quality stroke care throughout the region. In addition, the network provides member hospitals with 24-hour

Results

During 1 academic year, 120 patients underwent thrombolysis for acute stroke and admitted to the hub hospital. Because of the nature of the sizable stroke network, more patients were treated with drip-and-ship paradigm (n = 83, 69%). One hundred patients were discharged with the clinical diagnosis of AIS and 20 (16.7%) patients were discharged with other conditions that were grouped as SM. Of these 20 patients with SM, 14 had conversion disorder and 6 patients had other syndromes (2 patients

Discussion

This study confirms the most common causes for SM including psychiatric disorders, migraine, and epilepsy,4, 8 with the psychiatric disorders being the most common comorbidity. Concomitant psychiatric morbidity, specifically mood disorders and depression, is known to be associated with an increased prevalence of conversion disorder, typically in the setting of an acute stressor.18 More importantly, this study proves the hypothesis that SM are more common among those patients treated with

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