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Bakradze E, Shu L, Henninger N, Prabhakaran S, Siegler JE, De Marchis GM, Giles JA, Dittrich T, Heldner MR, Antonenko K, Kam W, Liebeskind DS, Simpkins AN, Nguyen TN, Yaghi S, Liberman AL. Delayed Diagnosis in Cerebral Venous Thrombosis: Associated Factors and Clinical Outcomes. J Am Heart Assoc 2023; 12:e030421. [PMID: 37753785 PMCID: PMC10727263 DOI: 10.1161/jaha.123.030421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/04/2023] [Indexed: 09/28/2023]
Abstract
Background Identifying factors associated with delayed diagnosis of cerebral venous thrombosis (CVT) can inform future strategies for early detection. Methods and Results We conducted a retrospective cohort study including all participants from ACTION-CVT (Anticoagulation in the Treatment of Cerebral Venous Thrombosis) study who had dates of neurologic symptom onset and CVT diagnosis available. Delayed diagnosis was defined as CVT diagnosis occurring in the fourth (final) quartile of days from symptom onset. The primary study outcome was modified Rankin Scale score of ≤1 at 90 days; secondary outcomes included partial/complete CVT recanalization on last available imaging and modified Rankin Scale score of ≤2. Logistic regression analyses were used to identify independent variables associated with delayed diagnosis and to assess the association of delayed diagnosis and outcomes. A total of 935 patients were included in our study. Median time from symptom onset to diagnosis was 4 days (interquartile range, 1-10 days). Delayed CVT diagnosis (time to diagnosis >10 days) occurred in 212 patients (23%). Isolated headache (adjusted odds ratio [aOR], 2.36 [95% CI, 1.50-3.73]; P<0.001), older age (aOR by 1 year, 1.02 [95% CI, 1.004-1.03]; P=0.01), and papilledema (aOR, 2.00 [95% CI, 1.03-3.89]; P=0.04) were associated with diagnostic delay, whereas higher National Institutes of Health Stroke Scale score was inversely associated with diagnostic delay (aOR by 1 point, 0.95 [95% CI, 0.89-1.00]; P=0.049). Delayed diagnosis was not associated with modified Rankin Scale score of ≤1 at 90 days (aOR, 1.08 [95% CI, 0.60-1.96]; P=0.79). Conclusions In a large multicenter cohort, a quarter of included patients with CVT were diagnosed >10 days after symptom onset. Delayed CVT diagnosis was associated with the symptom of isolated headache and was not associated with adverse clinical outcomes.
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Affiliation(s)
- Ekaterina Bakradze
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamALUSA
| | - Liqi Shu
- Department of NeurologyBrown UniversityProvidenceRIUSA
| | - Nils Henninger
- Department of NeurologyUniversity of Massachusetts Chan Medical SchoolWorcesterMAUSA
- Department of PsychiatryUniversity of Massachusetts Chan Medical SchoolWorcesterMAUSA
| | | | | | - Gian Marco De Marchis
- Department of NeurologyUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - James A. Giles
- Department of NeurologyYale University School of MedicineNew HavenCTUSA
| | - Tolga Dittrich
- Department of NeurologyUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Mirjam R. Heldner
- Department of NeurologyUniversity Hospital and University of BernBernSwitzerland
| | - Kateryna Antonenko
- Department of NeurologyUniversity Hospital and University of BernBernSwitzerland
| | - Wayneho Kam
- Department of NeurologyDuke University HospitalDurhamNCUSA
| | - David S. Liebeskind
- Department of NeurologyUniversity of California at Los AngelesLos AngelesCAUSA
| | - Alexis N. Simpkins
- Department of NeurologyUniversity of FloridaGainesvilleFLUSA
- Department of NeurologyCedars‐Sinai Medical CenterLos AngelesCAUSA
| | - Thanh N. Nguyen
- Department of NeurologyBoston University Chobanian and Avedisian School of MedicineBostonMAUSA
| | - Shadi Yaghi
- Department of NeurologyBrown UniversityProvidenceRIUSA
| | - Ava L. Liberman
- Clinical and Translational Neuroscience Unit, Department of NeurologyFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNYUSA
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Liberman AL, Holl JL, Romo E, Maas M, Song S, Prabhakaran S. Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. Acad Emerg Med 2023; 30:187-195. [PMID: 36565234 DOI: 10.1111/acem.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To date, many emergency department (ED)-based quality improvement studies and interventions for acute stroke patients have focused on expediting time-sensitive treatments, particularly reducing door-to-needle time. However, prior to treatment, a diagnosis of stroke must be reached. The ED-based stroke diagnostic process has been understudied despite its importance in assuring high-quality and safe care. METHODS We used a learning collaborative to conduct a failure modes, effects, and criticality analysis (FMECA) of the acute stroke diagnostic process at three health systems in Chicago, IL. Our FMECA was designed to prospectively identify, characterize, and rank order failures in the systems and processes of care that offer opportunities for redesign to improve stroke diagnostic accuracy. Multidisciplinary teams involved in stroke care at five different sites participated in moderated sessions to create an acute stroke diagnostic process map as well as identify failures and existing safeguards. For each failure, a risk priority number and criticality score were calculated. Failures were then ranked, with the highest scores representing the most critical failures to be targeted for redesign. RESULTS A total of 28 steps were identified in the acute stroke diagnostic process. Iterative steps in the process include information gathering, clinical examination, interpretation of diagnostic test results, and reassessment. We found that failure to use existing screening scales to identify patients with large-vessel occlusions early on in their ED course ranked highest. Failure to obtain an accurate history of the index event, failure to suspect acute stroke in triage, and failure to use established stroke screening tools at ED arrival to identify potential stroke patients were also highly ranked. CONCLUSIONS Our study results highlight the critical importance of upstream steps in the acute stroke diagnostic process, particularly the use of existing tools to identify stroke patients who may be eligible for time-sensitive treatments.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Jane L Holl
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elida Romo
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Matthew Maas
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Sarah Song
- Department of Neurology, Rush University, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
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Fartushna OY, Prokopiv MM, Palahuta HV, Bahrii RV, Hnepa YY, Fartushnyi YM, Selina OG. CLINICAL AND IMAGING FEATURES OF MEDIAL MEDULLARY INFARCTION: RESULTS OF A PROSPECTIVE HOSPITAL-BASED COHORT STUDY ILLUSTRATED WITH A CASE REPORT IN A WHITE EUROPEAN ADULT. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:2425-2429. [PMID: 36472273 DOI: 10.36740/wlek202210120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVE The aim: This study aims in a prospective hospital-based cohort study to determine clinical and imaging features of medial medullary infarction and report a relevant clinical case in a white European adult. PATIENTS AND METHODS Materials and methods: We have prospectively enrolled one hundred twenty adult patients with acute posterior circulation stroke. All patients were admitted and enrolled in the study within 6 to 24 hours from the onset of the stroke symptoms. Study subjects were recruited from the hospital's wards and emergency departments from 2011 to 2020. Comprehensive clinical, MRI, ultrasound, and laboratory examinations were performed on all patients. RESULTS Results: 68 men and 52 women aged 28 to 89 years (average age 60.7 ± 12.1 years) with an acute ischemic posterior circulation stroke were enrolled in the study. Out of these 120 patients, 22 (18.3%) had acute medulla oblongata infarctions. Clinical and imaging features of medial medullary infarction are analyzed and illustrated with a clinical case presentation in a white European adult. CONCLUSION Conclusions: Specific features of medial medullary infarction were determined, analyzed, described, and illustrated with a clinical case.
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Affiliation(s)
| | | | - Hanna V Palahuta
- STATE UNIVERSITY "UZHHOROD NATIONAL UNIVERSITY", UZHHOROD, UKRAINE
| | - Romana V Bahrii
- STATE UNIVERSITY "UZHHOROD NATIONAL UNIVERSITY", UZHHOROD, UKRAINE
| | - Yana Y Hnepa
- STATE UNIVERSITY "UZHHOROD NATIONAL UNIVERSITY", UZHHOROD, UKRAINE
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Liberman AL, Hassoon A, Fanai M, Badihian S, Rupani H, Peterson SM, Sebestyen K, Wang Z, Zhu Y, Lipton RB, Newman-Toker DE. Cerebrovascular disease hospitalizations following emergency department headache visits: A nested case-control study. Acad Emerg Med 2022; 29:41-50. [PMID: 34309135 PMCID: PMC8766867 DOI: 10.1111/acem.14353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Delayed diagnosis of cerebrovascular disease (CVD) among patients can result in substantial harm. If diagnostic process failures can be identified at emergency department (ED) visits that precede CVD hospitalization, interventions to improve diagnostic accuracy can be developed. METHODS We conducted a nested case-control study using a cohort of adult ED patients discharged from a single medical center with a benign headache diagnosis from October 1, 2015 to March 31, 2018. Hospitalizations for CVD within 1 year of index ED visit were identified using a regional health information exchange. Patients with subsequent CVD hospitalization (cases) were individually matched to patients without subsequent hospitalization (controls) using patient age and visit date. Demographic, clinical, and ED process characteristics were assessed via detailed chart review. McNemar's test for categorical and paired t-test for continuous variables were used with statistical significance set at ≤0.05. RESULTS Of the 9157 patients with ED headache visits, 57 (0.6%, 95% confidence interval [CI] = 0.5-0.8) had a subsequent CVD hospitalization. Median time from ED visit to hospitalization was 107 days. In 25 patients (43.9%, 25/57) the CVD hospitalization and the index ED visit were at different hospitals. Fifty-three cases and 53 matched controls were included in the final study analysis. Cases and controls had similar baseline demographic and headache characteristics. Cases more often had a history of stroke (32.1% vs. 13.2%, p = 0.02) and neurosurgery (13.2% vs. 1.9%, p = 0.03) prior to the index ED visit. Cases more often had less than two components of the neurologic examination documented (30.2% vs. 11.3%, p = 0.03). CONCLUSION We found that 0.6% of patients with an ED headache visit had subsequent CVD hospitalization, often at another medical center. ED visits for headache complaints among patients with prior stroke or neurosurgical procedures may be important opportunities for CVD prevention. Documented neurologic examinations were poorer among cases, which may represent an opportunity for ED process improvement.
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Affiliation(s)
- Ava L. Liberman
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA, Department of Neurology
| | - Ahmed Hassoon
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Departments of Epidemiology,The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Mehdi Fanai
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Shervin Badihian
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology
| | - Hetal Rupani
- The Johns Hopkins University School of Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Susan M. Peterson
- The Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland, USA
| | - Krisztian Sebestyen
- The Johns Hopkins University School of Medicine, Department of Surgery, Baltimore, Maryland, USA
| | - Zheyu Wang
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics, Baltimore, Maryland, USA,The Johns Hopkins Bloomberg School of Public Health, Departments of Biostatistics, Baltimore, Maryland, USA
| | - Yuxin Zhu
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics, Baltimore, Maryland, USA,The Johns Hopkins Bloomberg School of Public Health, Departments of Biostatistics, Baltimore, Maryland, USA
| | - Richard B. Lipton
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA, Department of Neurology
| | - David E. Newman-Toker
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, Departments of Epidemiology,The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA, Departments of Neurology,The Johns Hopkins University School of Medicine, Armstrong Institute Center for Diagnostic Excellence, Baltimore, Maryland, USA
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