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Published on: December 21, 2021
Identifying Missed Diagnostic Opportunities in Maternal Stroke
Noora Haghighi1, Raeann Marie Bourscheid1, Catherine Shang1
1Department of Neurology, Columbia University, New York, NY (N.H., R.M.B., C.S., E.C.M.).
Background:
Pregnancy-associated stroke may present with nonfocal symptoms, leading to missed diagnostic opportunities (MDO).
Methods:
We conducted a retrospective study including patients aged 18 to 50 years and pregnant or within 1 year of delivery, treated at 5 US comprehensive stroke centers from 2012 to 2021 for confirmed arterial ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, or cerebral venous thrombosis. Vascular neurologists at each site reviewed cases using a validated tool, Safer Stroke-Dx. We determined the proportion of cases with MDO and estimated 95% CIs based on a binomial distribution.
Results:
We identified 135 patients with pregnancy-related stroke (mean age, 32.4 [SD, 6.0] years), of whom 37 (27%) had MDO (95% CI, 20.6%-35.5%). Presenting symptoms included focal neurological deficits (57%; n=77), headache (53%; n=71), systemic symptoms (26%; n=35), and altered mental status (19%; n=25). More patients with MDO had hemorrhagic strokes (22 of 37 [59%] versus 34 of 79 [43%] patients with no MDO, and 10 of 19 [53%] with insufficient information to determine [P=0.05]). Among patients with MDO, 34 of 37 (92%) had ≥1 documented medical encounter in the month preceding stroke diagnosis compared with 47 of 79 (59%) individuals without MDO and 9 of 19 (47%) with insufficient information to determine (P<0.001). Of the 86 patients with prestroke encounters, most were evaluated by obstetricians (49%; n=42) or emergency medicine clinicians (29%; n=25). Among patients with MDO, contributing factors included failure to recognize symptoms (84%; n=31) and omission of appropriate neuroimaging studies (81%; n=30), despite that the clinical presentation was judged typical of the final stroke diagnosis in 35 of the 37 (95%) patients.
Conclusions:
In this retrospective cohort, >1 in 4 pregnant or postpartum patients with acute stroke experienced MDO. Our results suggest a need for enhanced clinician education, particularly for nonneurologists, in diagnosing stroke during pregnancy and the postpartum period.
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