Factors associated with hospitalization for ischemic stroke and TIA following an emergency department headache visit.
Factors associated with hospitalization for ischemic stroke and TIA following an emergency department headache visit.
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DOI：
10.1016/j.ajem.2020.10.082
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发表时间：
2021-08
期刊：
影响因子：
--
通讯作者：
Lipton RB
中科院分区：
文献类型：
--
作者：
Liberman AL;Lu J;Wang C;Cheng NT;Moncrieffe K;Lipton RB
有报道称急诊科头痛患者误诊为脑血管疾病。我们假设，即使在调整了人口统计学变量和病史之后，不符合标准的诊断过程的标记也与从急诊室出院的头痛诊断患者随后的缺血性脑血管事件有关。2013年9月1日至2018年9月1日，我们在蒙特菲奥里医学中心对被诊断为原发性头痛障碍的成年ED患者进行了一项病例对照研究。病例被定义为在指数ED就诊后365天内因缺血性中风或短暂性脑缺血发作而住院的患者。对照组患者被定义为那些没有随后因脑血管疾病住院的患者。比较两组间预先指定的人口学、临床和诊断过程因素；使用条件Logistic回归来评估基线特征对缺血风险的单独和联合影响。共有93名连续头痛并随后发生缺血性卒中/短暂性脑缺血发作的患者与93名对照组(n=186)配对。患者年龄比对照组大，更有可能有传统的脑血管危险因素。患者接受神经咨询的频率更高(13%比4%；P=0.0001)，在急诊室待的时间更长(6小时比5小时，P=0.03)，接受神经成像的频率更高(80%比48%；P<；0.0001)。病例和对照组的神经学检查、有文件记载的鉴别诊断和明确的出院随访计划的比率相似。在我们的条件Logistic回归模型中，只有既往卒中/短暂性脑缺血发作病史与随后发生脑缺血的几率增加相关。在我们的研究中，与诊断过程失败相关的因素不会增加ED头痛就诊后随后的缺血性中风/短暂性脑缺血发作住院的几率。
Misdiagnosis of cerebrovascular disease among Emergency Department (ED) patients with headache has been reported. We hypothesized that markers of substandard diagnostic processes would be associated with subsequently ischemic cerebrovascular events among patients discharged from the ED with a headache diagnosis even after adjusting for demographic variables and medical history. We conducted a case-control study of adult ED patients diagnosed with a primary headache disorder at Montefiore Medical Center from 9/1/2013–9/1/2018. Cases were defined as patients hospitalized for an ischemic stroke or TIA within 365 days of their index ED visit. Control patients were defined as those who lacked a subsequent hospitalization for cerebrovascular disease. Pre-specified demographic, clinical, and diagnostic process factors were compared between groups; conditional logistic regression was used to assess the separate and joint influence of baseline features on risk of ischemia. A total of 93 consecutive headache patients with a subsequent ischemic stroke/TIA were matched to 93 controls (n=186). Cases were older than controls and more likely to have traditional cerebrovascular risk factors. Neurological consultation was obtained more often for cases (13% vs. 4%; P=0.03), cases were in the ED for longer (6 vs. 5 hours, P=0.03), and more frequently received neuroimaging (80% vs. 48%; P<0.0001). Rates of neurological examination, documented differential diagnoses, and clear discharge follow up plans were similar between cases and controls. In our conditional logistic regression model, only history of prior stroke/TIA was associated with increased odds of subsequent ischemia. Factors associated with diagnostic process failures did not increase the odds of subsequent ischemic stroke/TIA hospitalization following ED headache visit in our study.
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