Stroke Misses Are Rare And Elusive In Telestroke Care

Background: Stroke mimic algorithms have been developed for use in telestroke systems of care but less is known about how frequently and what factors are associated with a clinically significant missed telestroke ischemic stroke diagnosis. We sought to examine the frequency and clinical characteristics of missed strokes (MS) in the VA National TeleStroke Program (NTSP) Methods: We analyzed NTSP consultations from April 2018 to September 2020. Consults with a telestroke diagnosis of “other” (not stroke/TIA) and a primary inpatient discharge diagnosis of ischemic stroke were chart reviewed. We applied the Oxfordshire stroke localization categories to all MRIs positive for acute ischemic stroke. Clinical outcomes were designated as MS-significant (MS-S) if symptoms of stroke persisted at discharge or rehabilitation was required, otherwise they were MS-not significant (MS-NS). Patient demographics, clinical conditions, last known well (LKW) and NIHSS were compared between the MS-S and MS-NS groups using Chi-square and t-tests. Results: Out of 3,163 consultations, 55 (1.7%) were identified as MS; 33 (60%) of these were MS-S, and 22 (40%) were MS-NS. The overall sample had a mean age of 72 years, mean LKW of 219 minutes prior to arrival, and median NIHSS of 3. Of those with MS, 46 (83.6%) had a brain MRI showing acute stroke; 30% partial anterior, 26% lacunar, 24% posterior. MS-S patients did not differ from MS-NS in age, race, LKW, NIHSS, stroke location or clinical diagnoses (Table). The most common diagnosis among MS was stroke recrudescence (25%). Conclusions: Clinically significant missed strokes were present in only 1% of more than 3,000 telestroke cases. Demographic and clinical features did not distinguish clinically significant misses from non-significant misses. Posterior circulation strokes represented almost a quarter of all MS. Implementing a rapid brain MRI protocol may be one way to avoid rare misses of acute ischemic stroke diagnosis via telestroke.