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BET 2: Missed diagnosis of ischaemic stroke in the emergency department
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  • Published on: 2 September 2020
    Erratum in Article Citations Noted on July 13, 2020
    • Alex A. Tarnutzer, Neurologist Kantonsspital Baden AG, Baden, Switzerland
    • Other Contributors:
      • David E. Newman-Toker, Neurologist

    This article draws its evidence from two citations, one by Madsen et al., and the other from a systematic review, which has been mis-cited as a duplicate of the Madsen reference. The correct citation to the systematic review is not Madsen et al., but Tarnutzer et al., PubMed ID 28356464 (Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017;88(15):1468-1477. doi:10.1212/WNL.0000000000003814.).

    Conflict of Interest:
    None declared.
  • Published on: 4 January 2019
    missed diagnosis of infective endocarditis-related stroke in the emergency department

    Failure to diagnose infective endocarditis(IE) as the underlying cause of embolic stroke merits recognition alongside failure to diagnose other subtypes of stroke,. The reason is that failure to recognise an infective basis for cerebral emboli precludes time-sensitive interventional strategies such as thrombectomy(1)(2) and, instead, exposes the patient to relatively contraindicated treatment options such as intravenous thrombolysis(IVT)(3)(4). One study compared outcomes from IVT in 222 patients(mean age 59) with IE-related stroke versus 134,048 subjects(mean age 69) with ischaemic stroke in the absence of IE. The rate of post-thrombolytic intracranial haemorrhage was significantly(P=0.006) higher in patients with IE-related stroke. The rate of favourable outcome was also significantly(P=0.01) lower in IE-related stroke(3). A high index of suspicion is required to diagnose IE-related stroke because both fever and heart murmurs are present in only a minority of IE patients at the time of presentation with stroke(4). For patients in whom a timely diagnosis of IE-related stroke is made thrombectomy appears to be a treatment option which generates a favourable outcome(1)(2).
    For the sake of completeness one also ought to mention the potential for meningovascular syphilis to be overlooked in a patient presenting with stroke both in HIV positive(5) and in HIV-negative subjects(6). In both instances neither IVT nor thrombectomy will suffice. Definitive treatment o...

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    Conflict of Interest:
    None declared.