Younger stroke victims benefit from earlier MRIs, ambulance rides to ER

Performing magnetic resonance imaging sooner on younger stroke patients entering emergency rooms can lower the rate of misdiagnosis and lead to faster appropriate treatment, according to a team of Wayne State University School of Medicine and Wayne State University Physician Group neurologists.

The Wayne State University-Detroit Medical Center Stroke Program team presented its findings February 11 during the American Heart Association/American Stroke Association's International Stroke Conference 2011 in Los Angeles, Calif.

In "Early Performance of MRI is Associated with Lower Rate of Stroke Misdiagnosis in Young Adults," the team examined the cases of 77 patients with a mean age of 37.9 years who reported to an emergency room displaying stroke symptoms. Of those cases, 14.5 percent of the patients were initially misdiagnosed.

The chances of a misdiagnosis decreased if physicians performed an MRI of the patient within 48 hours. The likelihood of a misdiagnosis increased as the age of the patients decreased. The study concluded that early performance of an MRI leads to greater accuracy of a stroke diagnosis in young adults brought to emergency rooms, and patients younger than 35 years of age are at greater risk of being misdiagnosed when exhibiting stroke symptoms. However, if a patient demonstrating stroke symptoms arrived via ambulance, there was a lower rate of misdiagnosis. The team hypothesized that arrival by ambulance may increase an emergency room staff's perception of the gravity of the patient's condition.

"Accurate diagnosis of stroke on initial presentation in young adults can reduce the number of patients who have continued paralysis and continued speech problems," said Seemant Chaturvedi, M.D., professor of Neurology and director of the WSU-DMC Stroke Program. "We have seen several young patients who presented to emergency rooms with stroke-like symptoms within three to six hours of symptom onset, and these patients did not get proper treatment due to misdiagnosis. The first hours are really critical."

"Part of the problem is that the emergency room staff may not be thinking 'stroke' when the patient is younger," Dr. Chaturvedi said. "Physicians must realize that a stroke is the sudden onset of these symptoms." Patients arriving with "seemingly trivial symptoms like vertigo and nausea" should be assessed meticulously, he said.

Delay can be costly. After 48 to 72 hours, there are no major interventions available to improve stroke outcome, he said.

Intravenous delivery of the clot-dissolving agent tissue plasminogen activator is the only U.S. government-approved treatment for acute stroke. The drug must be administered within three hours of symptom onset to reduce permanent disability.

The findings build on the team's 2009 study in which members reviewed seven years worth of data covering 57 patients between the ages of 16 and 50. The patients were enrolled in the Young Stroke Registry at the Comprehensive Stroke Center at the WSU School of Medicine. Four males and three females (average age 34) in the study were misdiagnosed with migraine headaches, vertigo, alcohol intoxication or other conditions. They were discharged from the emergency room, but later were found to have suffered a stroke.

Other team members who conducted the study include Pratik Bhattacharya, M.D., M.P.H.; Nandakumar Nagaraja, M.D.; Kumar Rajamani, M.D.; Ramesh Madhavan, M.D., D.M.; and Sunitha Santhakumar, M.D., all members of the Wayne State University Department of Neurology and the Wayne State University Physician Group.