The accuracy of the emergency physician at diagnosing CVA/TIA in the acute care setting

OBJECTIVE: To determine the accuracy of the ED physician at diagnosing CVA/TIA in the acute setting. METHODS: We reviewed 246 patients admitted for acute CVA/TIA during 1997. We reviewed admitting and discharge diagnoses, CT, MRI, and MRA results. We also reviewed the medical histories of the patients. Patients with tumors and ICH diagnosed on the initial CT scan were excluded. RESULTS: A total of 241 patients were included for analysis. Of the patients admitted for CVA, 67% were discharged with the same diagnosis. Of the patients admitted for TIA, 82% were discharged with the same diagnosis. 10% of TIAs diagnosed at admission received the diagnoses at discharge. 22% of CVAs at admission were diagnosed as TIAs. 11% of CVA/TIAs at admission were given other diagnoses at discharge. Some of these diagnoses included hemiplegic migraines, Bell's palsy, lumbosacral spondylosis, giant cell arteritis, basilar artery aneurysm, and viral meningitis. In considering thrombolysis for CVA, one may then overtreat approximately 30% of patients and miss approximately 10% of patients who could be candidates for treatment. The NNT for CVA and thrombolysis is approximately 10. If 30% overtreatment rate is accurate, then the NNH is approximately 333 assuming an ICH rate of 1%. For 1,000 patients treated, 100 may benefit (improved function) and 3 would die who did not have the disease. CONCLUSIONS: The accuracy rate of the diagnosis of CVA at initial presentation is 67%. This is due to many initial neurologic changes being TIAs and some other diagnoses which can mask as CVA. Choosing thrombolysis for CVA treatment will involve treatment of many patients who do not have disease.