stroke misdiagnosis disproportionate in the young says Washington Post

David Gordon, M.D. davidc.gordon at DUKE.EDU
Wed Jun 18 13:39:51 UTC 2014


A real challenge here is trying to separate the signal from the noise, and when it comes to neurologic complaints, there is unfortunately a lot of noise in emergency departments. Overcrowding and financial pressures further compound the difficulty of who requires the full work-up.

I think risk stratification is key to this issue. We have imperfect but overall good processes and tools in place for the risk stratification of ACS and pulmonary embolism. As an emergency physician, I don't feel I have the same cognitive tools available for independently risk stratifying TIA/stroke. I am fortunate to work in a clinical environment where I have ready access to neurology consultation to assist in the process and an observation protocol for equivocal/intermediate cases, but I gather to say this is far from the norm.

As far as the treatment of neurologic complaints in the emergency setting, we need more evidence. It is going to take prospective analysis of all-comers to the ED with stroke-like symptoms to better understand who needs immediate work-up and who can be safely discharged. Perhaps we will end up with 2 different stratification tools- one for the young and one for the old.

As far as whether diagnostic aids will be utilized or ignored due to CDRs, I think it depends. If the rule has good performance, easy to use, and is bought into by both emergency physicians and neurologists, I do think it would be readily employed - especially if the evidence becomes increasingly convincing that the epidemiology of stroke is changing (or becoming better understood) and young patient's are being misdiagnosed.


David Gordon, MD
Associate Professor
Undergraduate Education Director
Division of Emergency Medicine
Duke University

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From: David Newman-Toker [toker at JHU.EDU]
Sent: Tuesday, June 17, 2014 2:56 PM
Subject: [IMPROVEDX] stroke misdiagnosis disproportionate in the young says Washington Post

Stroke is a major public health problem, and recent work suggests young patients are having more strokes, with rates rising alarmingly in recent years, according to an article in today’s Washington Post…

They are also much more likely to be misdiagnosed (7-fold greater risk in those 18-45 relative to those >75)…



David E. Newman-Toker, MD, PhD
Associate Professor, Department of Neurology
Johns Hopkins Hospital, Meyer 8-154; 600 North Wolfe Street, Baltimore, MD 21287
Email: toker at<mailto:toker at>; 410-502-6270 (phone); 410-502-6265 (fax)
Web address: Johns Hopkins Neurology (David Newman-Toker)<>

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