Background: Patients with symptoms that simulate Acute Ischemic Stroke (AIS), but are ultimately determined to have another diagnosis are referred to as Stroke Mimics (SM). SM are reported to be 1.4% to 30% of Emergency Department (ED) cases, and reducing door-to-needle time (DTN) has been associated with increased treatment of SM (from 6.7% to 30%). The risk of tPA in SM patients is unclear. We are challenged with the conflicting goals of timely administration of therapy and mitigating unnecessary risk. We successfully reduced DTN and were interested to see if that effected SM.
Objectives: To evaluate the impact of DTN on diagnostic accuracy in patients receiving tPA in the ED; and to determine the associated complication rate in patients with AIS compared to SM.
Methods: We performed a retrospective cohort study of patients receiving tPA for suspected AIS between 2013-2015. Patients were identified through our Stroke registry and confirmed by pharmacy audit of tPA orders. We performed a structured chart review and provide a descriptive analysis of variables.
Results: In our study period, 97 patients were treated with tPA for the presumptive diagnosis of AIS, 90 (92.8%) had a final diagnosis of AIS, while 7 (7.2%) were SM. The only complications of treatment with tPA reported were in the AIS group, 4 (15%) and 1 (4.2%) in 2013/2014 repectively. There were no complications reported in either group in 2015. This reduction in complications was achieved while reducing the DTN to less than 45 min in 50% of patients and less than 60 min in 75% of patients.
Conclusion: While doubling the number of patients treated, we reduced the DTN and the complication rate in AIS patients. Contrary to prior studies, we found a decrease in the number of SM treated. None of the SM patients had a complication. The reduction in DTN and SM over time suggests that our screening of tPA candidates is appropriate.