It is not uncommon for young adults with stroke to be misdiagnosed
during initial presentation to the emergency department, particularly
if they experience an infarct in their posterior circulation.

New research presented here at the American Stroke Association
International Stroke Conference 2009 shows an overall misdiagnosis
rate of 14% among adults under the age of 50 years.

"In these individuals, we also found there was a strong trend among
the very youngest patients ¡X those under age 35 ¡X to have an even
greater chance of misdiagnosis," principal investigator Seemant
Chaturvedi, MD, from Wayne State University, in Detroit, Michigan,
told Medscape Neurology.

Dr. Chaturvedi said his own anecdotal experience and that of some of
his colleagues led them to look into the issue of misdiagnosis in
young stroke patients.

"I think we've all seen young patients who, even though they have
presented to the emergency department early after symptom onset, do
not receive the proper diagnosis. When that happens, patients are
deprived of the opportunity to receive [tissue plasminogen activator]
tPA or interventional stroke therapy, so we decided to look at this
issue in a more systematic way," he said.

Inner-Ear Disorder Diagnosed in 50%

The researchers reviewed data on 57 patients aged 16 to 50 years
enrolled since 2001 in the Young Stroke Registry at the Comprehensive
Stroke Center at Wayne State University.

With an average age of 34 years, 8 patients ¡X 4 males and 4
females ¡X were misdiagnosed with conditions including alcohol
intoxication, migraine, vertigo, and inner-ear disorder.

Of these, half were diagnosed with an inner-ear disorder, including
labyrinthitis or peripheral vertigo, and subsequently ended up being
diagnosed with stroke in the brain stem or cerebellum. One 18-year-
old patient diagnosed with alcohol intoxication also ended up with a
diagnosis of posterior cerebral artery stroke.

Of the misdiagnosed cases, 7 of the 8 presented within 3 hours to the
emergency department. Of these, said Dr. Chaturvedi, 3 would have
been considered good candidates for thrombolysis.

A Diagnostic Challenge

Diagnosing posterior stroke can be challenging, said Dr. Chaturvedi.

"There are a number of neural pathways in the brain stem that can
affect different functions, including strength, coordination, speech,
eye movements, hearing, and swallowing. So to a nonspecialist, it can
be challenging to tease out which of these are serious and which are
benign," he said.

Nevertheless, he added, the presenting signs and symptoms in these
misdiagnosed patients were not atypical.

"It may be that physicians are just not expecting stroke [in these
young patients]. A lot of the presentations were classic for stroke,
but for whatever reason, they just weren't recognized as such," he
said.

Dr. Chaturvedi said the study highlights the need for efforts to
increase awareness among the public and clinicians that stroke can
occur in young people. He estimated that in the United States there
are approximately 10,000 to 15,000 strokes in individuals under the
age of 45 years annually.

"I think I would recommend that doctors consider a diagnosis of
stroke in patients who present with acute neurologic deficits,
regardless of age. It is particularly important in patients who
present with dizziness to evaluate patients' gait, speech, and eye
movements before concluding their condition is benign."

Dr. Chaturvedi said his future research will examine potential
differences between misdiagnosis rates in designated and undesignated
stroke centers.

International Stroke Conference 2009: Abstract 33. Presented February
18, 2009.