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Young stroke patients: They're often misdiagnosed
A 32-year-old obese female patient arrived at Columbus, OH-based Riverside Methodist Hospital's ED at 7:55 a.m. Her exam revealed left facial droop, flaccid left arm and leg, decreased sensation on the left, and visual field deficit to the left. The woman had a National Health Institutes Stroke Scale (NIHSS) score of 16 and persistent left-sided paralysis.
The stroke team was activated, and a stat CT of the brain was obtained that revealed small, early ischemic changes and the appearance of acute occlusion of right internal carotid including right carotid terminus and middle cerebral artery.
"She was immediately transported to the interventional radiology suite for possible endovascular intervention," says Carl Bricker, RN, ED manager.
Because the patient was inside the three-hour window for intravenous tissue plasminogen activator (tPA), the infusion was started at 9:12 a.m. Aggressive stroke treatment "saved this young woman from a devastating disability," recalls Bricker.
Would it surprise you to learn that stroke patients under the age of 35 were misdiagnosed one-third of the time? That finding comes from researchers at Wayne State University School of Medicine in Detroit.1 The study's findings underscore the importance of considering the diagnosis of stroke regardless of age when patients present with the sudden onset of neurologic symptoms such as dizziness, trouble walking, and/or speech difficulty, says Seemant Chaturvedi, MD, the study's author and director of the stroke program at Wayne State University/Detroit Medical Center.
According to Chaturvedi, "emergency room personnel need to have a heightened sensitivity to the possibility of stroke in people under 45." In addition, consider getting neurology consults in the ED for patients with sudden onset of these symptoms. "It is important to assess the patient's gait before discharging them," Chaturvedi adds.
Younger patients oftentimes present with vague symptoms, and these symptoms often are waived off as "nothing" or "it will go away," says Tia Moore, RN, CEN, an ED clinical nurse educator at University of California — San Diego Medical Center. "The young patient often thinks, 'This will never happen to me.' The ED staff tends to call this type of patient as 'The Teflon Don,'" she says. "This false sense of security within the younger community tends to increase the risk of residual damage post-stroke. Time is tissue, and the longer they play it off, the more severe the residual can become."
"The assessment for the younger population is not much different than the older population, except for a couple of areas," says Bricker.
Check meds, trauma, and surgery
In a younger patient, pay particular attention to the history of any drug abuse, the use of oral contraceptives, any other medication use, and recent trauma or surgery, he says. "A diagnostic concern to check is that of a carotid dissection as a cause or hypercoagulation that has yet been diagnosed," says Bricker.
Give a stroke work-up to any patient who presents with weakness, numbness, or tingling of any extremity, says Bricker. This stroke work-up is especially needed if the symptom is affecting unilaterally the upper and lower extremity, or the patient has facial droop, aphagia, sudden headache, or the "worst headache of their life." "Our goal here at Riverside is to call a stroke alert on any patient that has an NIHSS score of over 3," says Bricker.
Suspect stroke? Check drugs/herbs, glucose
When assessing for stroke in younger patients, ask about usage of illicit drugs as well as herbal medications, advises Tia Moore, RN, CEN, clinical nurse educator at the University of California — San Diego Medical Center.
"Many times young patients arrive into the ED with stroke symptoms, and after inquiry it has been learned that they are taking natural supplements to bulk up their bodies or have recently used illegal drugs," says Moore. "These, when ingested or smoked, can mimic stroke symptoms."
Moore also notes that hypoglycemia can mimic a stroke, and many herbal supplements tend to decrease glucose and glycogen stores within the body due to increased metabolism. "Glucose checks should be done immediately on anyone who presents with stroke symptoms, regardless of age," says Moore.