With all the various competing interests for time, it’s rare to find an article of sufficient note to warrant its own blog post. A notable publication might get a short tweet thread. Collections of other literature find their way into ACEPNow articles or the odd Annals of Emergency Medicine Journal Club. But, every once in awhile, there’s something … else.
This article pertains to the practice of telestroke administration of thrombolysis for acute ischemic stroke. In major hospital centers, there may be in-house neurology hospitalists or stroke and vascular specialists, and the expertise for management of stroke is readily at the bedside. In many community, regional, and rural hospitals, these resources are unavailable – except by telestroke evaluation. These common arrangements allow access to neurology expertise, followed potentially by interhospital transfer.
In this article, the authors review a series of 270 patients receiving intravenous thrombolysis following evaluation via telestroke. Most patients underwent MRI with DWI following transfer to the hub stroke center, while a handful did not – probably those with serious complications arising from stroke, and those with obvious stroke mimic etiologies. Patients otherwise were categorized as a stroke if a lesion was found on MRI with DWI, but could be deemed a TIA or a stroke mimic if no lesion was seen.
Not-so astonishingly, they report 23.7% of their series are stroke mimics. Another ~5% are TIA, another diagnosis for which there is no indication for thrombolysis. While this much collateral damage might horrify some, this sort of blanket use of thrombolytics is routine in the United States, if not encouraged. The proof of such encouragement is evidence in these authors’ Discussion section, with this interpretation of recent guidelines:
In fact, the most recent AHA guidelines in 2019 recognise this and specifically recommend thrombolysis to SM given the low rate of sICH and state that starting IVtPA is preferred over delaying treatment to pursue additional diagnostic studies.
Naturally, the authors go on to propose a threshold of reasonable practice for which their performance fits comfortably within:
In our academic tertiary referral telestroke programme, 23.7% of patients administered thrombolysis had a final diagnosis of SM. We suggest that a reasonable SM thrombolysis rate for telestroke programme should be one in four, similar to the accepted negative appendectomy rate, as that the risk of overtreatment should be accepted over the risk of undertreatment.
This is, of course, nonsensical. Leaving aside their entirely specious comparison to an acceptable negative appendectomy rate, let us ruminate seriously on the response to a poorly performing process being to normalize the poor performance. The authors rightfully cite Jeff Saver’s general musings that, given the advancing state of the specialty, the acceptable stroke mimic rate ought to be around 3%. They then justify their absurdly higher total by noting a small portion – about 7-10% – of eligible strokes are missed for treatment, and it is rather the better practice to simply treat any potential stroke in order not to miss a single one.
Again, this perspective hinges primarily on the concept treating stroke mimics with thrombolysis is “harmless“, owing to a rate of sICH of merely ~0.5-1%. While this is still an unacceptable perspective towards inducing sICH in an otherwise unsuspecting patient, the other harms for thrombolysis in stroke mimics include:
- Diagnostic inertia, in which evaluation and treatment for the true cause of neurologic dysfunction is delayed.
- Permanent misdiagnosis, in which a patient treated with thrombolysis, improves, and is labelled an “aborted stroke”. They now carry the diagnosis of prior stroke, making it potentially more difficult to obtain health insurance, not to mention likely unnecessarily being prescribed medications for secondary prevention of stroke.
- Financial harms from being treated with thrombolysis, which typically requires extended monitoring in a critical care or stroke unit, far exceeding the costs associated with a non-stroke hospitalization.
In short, this is a grossly unacceptable perspective endorsing, frankly, reckless use of thrombolysis. These authors should reconsider the primarily literature they are citing as justification and the framing of their argument, and retract their call to normalize these poorly performing clinical systems.
“Thrombolysis of stroke mimics via telestroke”
https://svn.bmj.com/content/7/3/267