Misdiagnosing Strokes: Can Doctors Miss The Signs?

Stroke is a medical emergency that requires immediate attention. The timely diagnosis of a stroke is crucial as it can significantly impact the patient's outcome and risk of recurrence. However, it is important to note that misdiagnosis of stroke does occur and can have serious consequences. The challenge of diagnosing a stroke falls on both the patient, who must recognise the symptoms and seek medical attention promptly, and the doctor, who must accurately identify the condition and initiate appropriate treatment.

Misdiagnosis of stroke type

Stroke misdiagnosis can have serious consequences, including preventable deaths and long-term disability. It is important to understand the factors that contribute to stroke misdiagnosis and develop interventions to reduce them.

There are several types of strokes, and misdiagnosis can occur when the presenting symptoms are non-specific, mild, or transient. The most common type of stroke is ischaemic stroke, which occurs when a blood clot blocks blood flow to the brain. Haemorrhagic stroke, on the other hand, is caused by a burst blood vessel. A transient ischaemic attack (TIA or mini-stroke) is a third type of stroke where the symptoms do not last long (less than 24 hours).

One study found that missed diagnoses of stroke in emergency departments occurred in 12.7% of stroke admissions, with missed ischaemic strokes being more common than haemorrhagic strokes. Symptoms such as dizziness and headache were often misdiagnosed, while traditional stroke symptoms like hemiplegia were rarely missed.

Additionally, certain demographic factors may increase the risk of stroke misdiagnosis. Younger patients, women, and minorities are more likely to be misdiagnosed. In terms of medical factors, patients with private insurance and those treated in non-teaching hospitals or low-volume hospitals also had higher odds of misdiagnosis.

To reduce the risk of misdiagnosis, it is important for physicians to be vigilant, especially when evaluating younger, female, and non-White patients with symptoms such as dizziness and headache. Early treatment and timely diagnosis are crucial in improving stroke outcomes and lowering the risk of recurrent stroke.

Non-specific symptoms

• Dizziness
• Headache without mental status change
• Temporary numbness
• Emotional issues, like laughing or crying at inappropriate times
• Changes to your way of walking
• Getting lost in places that should be familiar
• Trouble making decisions
• Losing bowel and bladder control
• Changes in your mood
• Decreased ability to think

These symptoms are often mistaken for signs of aging or other conditions, such as benign dizziness or headaches. However, it is important to recognize that strokes can present with "atypical" or "mild" symptoms, especially in younger patients, women, and minorities. Therefore, physicians should be vigilant and consider the possibility of stroke in patients presenting with these non-specific symptoms.

Patient characteristics

Gender is also a factor, with women having greater odds of a misdiagnosis, possibly due to a greater frequency of non-classic stroke presentations. Racial disparities are evident, with Black, Asian/Pacific Islander, and Hispanic patients having higher odds of a missed stroke diagnosis than non-Hispanic White patients. This may be influenced by differences in diagnostic stroke workups for Hispanics.

Insurance status and income levels also come into play. Privately insured patients have higher odds of a missed stroke diagnosis compared to those on Medicare or Medicaid. However, income levels do not seem to have an incremental association with missed strokes.

Additionally, the presence of medical comorbidities is a factor, as each additional comorbidity decreases the odds of a missed diagnosis. This could be because comorbidities increase the suspicion of stroke or make admission more likely.

Hospital characteristics

Hospitals play a crucial role in the accurate and timely diagnosis of strokes, and certain hospital characteristics have been found to influence the likelihood of missed or delayed diagnoses. Here are some key findings regarding hospital characteristics and their impact on stroke diagnosis:

• Hospital Size and Location: The size and location of a hospital can affect the accuracy of stroke diagnosis. Patients in small metropolitan areas had lower odds of stroke misdiagnosis compared to those in large metropolitan areas. This finding suggests that hospitals in less populated regions may have better stroke diagnosis capabilities or protocols in place.
• Teaching Status: Teaching hospitals, which are often affiliated with academic institutions and involved in medical education and research, had lower odds of stroke misdiagnosis compared to non-teaching hospitals. This could be attributed to the availability of more specialized staff, advanced technologies, and a culture of continuous learning and improvement.
• Hospital Volume: Hospital volume, referring to the number of patients treated or procedures performed, is another factor influencing stroke misdiagnosis rates. Hospitals with high annual emergency department (ED) volume had lower odds of misdiagnosis. This may be due to greater expertise and efficiency gained from treating a higher volume of patients.
• Diagnostic Resources and Expertise: Hospitals with access to advanced neuroimaging technologies, such as MRI and CT scans, and specialized neurology services are more likely to accurately diagnose strokes. The availability of these resources and expertise can significantly impact the accuracy and timeliness of stroke diagnosis.
• Hospital Workflow and Efficiency: The efficiency and workflow within a hospital can also impact stroke diagnosis. Hospitals with higher overall annual admission rates from the ED and higher ED admission rates on the day of the visit were associated with lower odds of misdiagnosis. This suggests that hospitals with streamlined processes and efficient patient flow may improve diagnostic accuracy.
• Disparities in Hospital Care: It is important to acknowledge that disparities exist in stroke diagnosis and treatment across different hospitals. Factors such as hospital location, size, and teaching status can contribute to variations in care quality. These disparities can lead to inequities in health outcomes for patients from different demographic and socioeconomic backgrounds.

Further research and interventions are needed to address these disparities and improve stroke diagnosis accuracy across all hospitals, regardless of their characteristics. Standardized protocols, staff training, and access to specialized resources can help reduce missed or delayed stroke diagnoses and improve patient outcomes.

Imaging tests

Computed Tomography (CT) Scan

A CT scan is often one of the first imaging tests used for stroke diagnosis. It employs X-rays to capture detailed images of the brain, revealing bleeding, damage to brain cells, or other issues that could be causing stroke symptoms.

Magnetic Resonance Imaging (MRI)

MRI scans utilize strong magnets and radio waves to generate images of the brain. This technique is more sensitive than a CT scan in detecting early brain changes caused by a stroke. It can also identify bleeding, blood flow problems, and rule out other conditions like tumors.

CT or MR Angiogram

An angiogram is an X-ray movie of the blood vessels, providing a dynamic view of blood flow. A CT angiogram is used in conjunction with a CT scanner, while an MR angiogram is paired with an MRI. A dye is injected into the veins to visualize the blood vessels post-stroke.

Carotid Ultrasound

This test employs sound waves to create images of the carotid arteries, which are responsible for supplying blood to the brain. It is often used alongside a CT or MR angiogram to check for plaque buildup that could be obstructing blood flow to the brain.

Trans-cranial Doppler (TCD) Ultrasound

The TCD ultrasound, also used with a CT or MR angiogram, helps identify which artery in the brain is blocked. It utilizes sound waves to measure blood flow and provide valuable information for stroke diagnosis and treatment planning.

These imaging tests offer doctors valuable tools to visualize the brain, assess the damage caused by a stroke, and determine the type and cause of the stroke, all of which are crucial for developing an effective treatment plan.

Frequently asked questions