Missed Opportunities for Recognition of Ischemic Stroke in the Emergency Department

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Evidence suggests that a significant number of patients discharged from the hospital with a diagnosis of ischemic stroke are not identified as having a stroke on admission. Those presenting with “nontraditional” stroke symptoms may be less likely to be diagnosed correctly. We aimed to establish whether there was an association between symptom presentation and diagnostic accuracy and to identify the type and frequency of nontraditional symptoms that resulted in a missed diagnosis in the emergency department.


We reviewed the medical records of 189 patients discharged with a diagnosis of ischemic stroke from Yale-New Haven Hospital. We performed χ2 analysis to determine whether an association existed between symptom presentation and diagnostic accuracy. Descriptive statistics allowed us to identify symptom type and frequency in patients with a missed diagnosis.


A diagnosis of suspected stroke was missed in 15.3% of patients who presented to the emergency department. We found a strong association (P < 0.0001) between symptom presentation and diagnostic accuracy. Of the patients presenting with any “traditional” symptom, 4% were missed. Of those presenting with only nontraditional symptoms, 64% were missed (odds ratio, 43.4; 95% confidence interval, 15.0-125.4). Nontraditional symptoms included generalized weakness, altered mental status, altered gait, and dizziness.


In order to facilitate appropriate management of patients with ischemic stroke, emergency nurses must be aware that symptom presentation is highly variable. Patients presenting with nontraditional symptoms may benefit from an immediate and comprehensive neurological evaluation.

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