Neurological Emergency Department Research Articles

Headache Characteristics in the Neurological Emergency Department: A Retrospective Study.

Background: The care of patients with headache in the emergency department (ED) represents a diagnostic and clinical challenge. Data on the prevalence and characteristics of headache patients in purely neurological EDs are sparse. The aim of the present study is to examine patient profiles with the cardinal symptom of headache in an academic neurological ED, to analyze correlations between headache characteristics and search for differences compared to the interdisciplinary ED.Methods: This retrospective cross-sectional study assessed all patients who presented to the ED of the Department of Neurology at Rostock University Medical Center between November 2013 and November 2016 with the main symptom of headache. Epidemiological, clinical, diagnostic data as well as key data regarding the care structure were recorded. Correlations between headache characteristics and diagnosis at discharge were analyzed and risk profiles were identified using binary logistic regression analysis.Conclusion: This study comprehensively characterized a large collective of patients with the cardinal symptom of headache presenting to a purely neurology emergency department.

Lyme neuroborreliosis-associated cerebrovascular events in the Finnish endemic area

ObjectivesNeuroborreliosis is a rare cause of cerebral vasculitis and stroke. The incidence of Lyme borreliosis in Finland has been increasing in the last 20 years, so we expect that Lyme neuroborreliosis–associated vasculitis can be a more common cause of stroke in the future. Materials & methodsWe have retrospectively identified all adult patients (>16 years old) diagnosed with borreliosis (A69.2 Lyme borreliosis), transient ischemic attack (TIA, G45), and ischemic stroke (I63) at Helsinki University Hospital during 1.1.2014–31.10.2019 at our neurological emergency department. Medical data and follow-up data were retrospectively collected from medical records. Neuroborreliosis was diagnosed according to the European Federation of Neurological Societies guidelines. ResultsWe have identified 10 cases of neuroborreliosis–associated stroke or TIA and/or vasculitis. Vasculitis as a manifestation of borreliosis was diagnosed in six patients of 1454 (0.4%) and stroke or TIA in nine (0.6%) of all borreliosis patients at Helsinki University Hospital. Clinical outcomes for all our patients were good with a modified Rankin scale (mRS) 0–2. ConclusionsLyme neuroborreliosis–associated vasculopathy and cerebrovascular events still remain rare but should be considered especially in Lyme borreliosis endemic areas. Prognosis is good with appropriate antibiotic treatment, but additional immunosupressive treatment is sometimes needed.

The Impact of Patient’s Fear of COVID-19 Infection on Neurology Service in University Hospital Center Sestre Milosrdnice During COVID-19 Epidemic Outbreak

Increasing evidence suggests that patients with medical emergencies are avoiding the emergency department because of fear of coronavirus disease 2019 (COVID-19) infection, leading to increased morbidity and mortality due to other diseases. In order to analyse the impact of patient’s fear of COVID-19 on the admittance rate of stroke patients and severity of neurological diseases, we compared the stroke admittance rate, numbers of thrombectomies and thrombolysis and hospitalization refusal rate during the time period from March 1st until June 30th 2020 in temporal relationship with the rising numbers of COVID-19 cases in Croatia. We assessed the patients’ neurologic disease severity measured by ventilation time and mortality rate in the same time period. We compared the data with the data obtained from the same time period in 2019. We observed dramatically decreased presentation in Neurologic Emergency Department due to stroke and neurologic disease in 2020 compared to 2019, increased refused hospitalization rate and similar stroke treatment rate despite bigger catchment area. Greater neurologic disease severity with almost 40% increased ventilation time and double mortality rate during the same time was observed. During the outbreak of COVID-19 epidemic, fear of infection had significant impact on neurologic service leading to decreased presentation to NED, resulting in increased stroke or neurologic disease-related morbidity and mortality.

Functional Neurological Disorder in a neurological emergency department during the COVID-19 pandemic (2615)

Functional Neurological Disorder in a neurological emergency department during the COVID-19 pandemic (2615)

Abstract P168: Who Are You Going to Call?: Emergency Physician Stroke Champions

Introduction: A 2013 study supported by the American Academy of Neurology showed an 11% shortage of neurologists with a projected 19% shortage by 2025. An additional supply of 3000 neurologists is needed by 2025 to meet the looming demand. To help ease the shortage, teleneurology has been implemented by neurologists, mainly for acute stroke patients. We present our model of emergency physician Stroke Champions (SCs) to direct care for stroke patients. Methods: Administering thrombolytics for stroke is a key component of emergency medicine core competencies. Our health system consists of 4 hospitals; a main hub and 3 spoke hospitals. The hub hospital innovatively developed a Neurologic Emergency Department (Neuro ED) with 5 board certified emergency physicians dedicated to caring for patients with any type of neurological complaint. The Neuro ED physicians are also designated as SCs that have specialized training to provide teleneurology to fellow emergency physicians caring for acute stroke patients at the additional hospitals. This supplementary training consists of a mini neurology fellowship with rotations through the neurologic ICU, specialized stroke floor, neurointerventional suite, and neuroradiology. Results: Over a 90-day period the command center received 67 phone calls for patients that met stroke alert criteria. Calls entailed managing BP, dosing alteplase, and recommendations for advanced neuroimaging. Most importantly, the SCs extensively reviewed inclusion and exclusion criteria for IV alteplase with the spoke emergency physician. Three patients were deemed eligible for IV alteplase, with no cases of intracranial hemorrhage. Seven patients required transfer and was facilitated by the SCs, reducing any delays. Reasons for transfer included 3 cases of hemorrhagic stroke, 3 large vessel occlusions for mechanical thrombectomy - one of which received IV alteplase, and 1 brain tumor. Conclusion: Teleneurology is a reliable means of reaching and treating stroke patients. With the severe current shortage of neurologists in the U.S., we now demonstrate a promising alternative of emergency physician Stroke Champions providing telestroke care. This model has produced a high success rate raising the standard of acute neurological care.

Crisis epilépticas en urgencias: aspectos clínicos y diagnósticos de una serie de 153 pacientes

IntroductionSeizures are a frequent reason for admission to emergency departments and require early, precise diagnosis and treatment. The objective of this study was to describe the clinical and prognostic characteristics of a series of patients with seizures attended at our hospital's emergency department. MethodsWe performed a retrospective, observational study of all patients with seizures who were admitted to our hospital's emergency department and attended by the on-call neurology service between February and August 2017. ResultsWe included 153 patients, representing 9.9% of all neurological emergency department admissions. The median age was 58 years, 52.3% of patients were women, and 51% had history of epilepsy. Onset was focal in 82.4% of cases, and the most frequent aetiology was cerebrovascular disease (24.2%). Twelve patients (7.8%) developed status epilepticus, which was associated with higher scores on the ADAN scale (P<.001) and with history of refractory epilepsy (P=.002). The in-hospital mortality rate was 3.7%, and in-hospital mortality was associated with older age (P=.049) and status epilepticus (P=.018). Eighty percent of patients with no history of epilepsy were diagnosed with epilepsy at the emergency department; all started treatment. The kappa coefficient for epilepsy diagnosis in the emergency department compared to diagnosis after one year of follow-up by the epilepsy unit was .45 (diagnosis was modified in 20% of patients). ConclusionsSeizures are a frequent neurological emergency with potential complications and considerable morbidity and mortality rates. In patients with no known history of epilepsy, the condition may be diagnosed in the emergency department, but follow-up at specialised epilepsy units is recommended.

Blend Sign Is a Strong Predictor of the Extent of Early Hematoma Expansion in Spontaneous Intracerebral Hemorrhage.

Background and Purpose: It is unclear which imaging marker is optimal for predicting the extent of hematoma expansion (EHE). We aimed to compare the usefulness of the blend sign (BS) with that of other non-contrast computed tomography (NCCT) markers for predicting the EHE in patients with spontaneous intracerebral hemorrhage (sICH).Methods: Patients with sICH admitted to our Neurology Emergency Department between September 2013 and January 2019 were enrolled. The EHE was calculated as the absolute increase in hematoma volume between baseline and follow-up CT (within 72 h). The EHE was categorized into four groups: “no growth,” “minimal change” (≤5.1 ml), “moderate change” (5.1–12.5 ml), and “massive change” (>12.5 ml). Univariate and multivariate analyses were performed to investigate the relationship between the NCCT markers [BS, black hole sign (BHS), satellite sign, and island sign] and the EHE.Results: A total of 1,111 sICH patients were included (median age: 60 years; 66.5% males). Multiple linear regression analysis showed that the presence of the BS and BHS was independently associated with the EHE, after adjusting for confounders (P < 0.001 and P = 0.003, respectively). The presence of the BS and BHS was positively correlated with growth category (r = 0.285 and r = 0.199, both Ps < 0.001). The BS demonstrated a better predictive performance for the EHE than did the BHS [area under the curve (AUC): 0.67 vs. 0.57; both Ps < 0.001].Conclusions: In patients with acute sICH, the BS showed a better performance in predicting the EHE compared with other NCCT markers. This imaging marker may help identify patients at a high risk of significant hematoma expansion and may facilitate its early management.

Neurology practice and stroke services across East China: a multi-site, county-level hospital-based survey

BackgroundNeurological disorders are an economic and public health burden which requires efficient and adequate medical resources. Currently, little is known about the status of the quality of neurological care services available in China. As neurological primary care is mostly provided at the county hospital level, investigation of this geographical level is required. The aim of this study is to evaluate currently available neurology care services in Yangtze River Delta Urban Agglomerations in east China.MethodsA multi-site, county-level hospital-based observational survey was conducted in east China from January 2017 to December 2017. A questionnaire was made to assess hospital and the departmental patient care capabilities, human resources and technical capacity in neurology departments.ResultsOf 228 hospitals across the Yangtze River Delta Urban Agglomerations, 217 documents were returned. Of these, 22 were excluded due to invalid hospital information or duplicate submission. Overall, most hospitals have neurology departments (162, 83.1%) while less than half of the hospitals have a stroke center (80, 41.0%) and neurology emergency department (46, 23.6%). Among 162 hospitals with neurology department, 5 were excluded due to inadequate sharing, leaving 157 hospitals for analysis. About 84.1% of these neurology departments can administer intravenous thrombolysis while about one third of them has the ability to perform arterial thrombectomy (36.9%). In addition, 46.2% of hospitals can carry out computed tomography angiography (CTA) in emergency room. Tertiary care hospitals are much more equipped with modern medical resources compared to the secondary hospitals. In four administrative regions, the neurology services are better in more economically advanced regions.ConclusionsNeurological care services need to be enhanced at the county-level hospitals to improve health care delivery.

Innovations in Care Delivery of Stroke from Emergency Medical Services to the Neurointerventional Operating Room.

Acute ischemic stroke (AIS) and its care is currently one of the most dynamic and evolving illnesses across the globe. Among the most crucial factors in providing the best care to patients are the expedient delivery of thrombolytics and endovascular intervention when indicated. Here, we review our unique model of efficient care centered in our innovative Neurological Emergency Department (Neuro ED). The Neuro ED acts as our hub for EMS communication, imaging, administration of intravenous alteplase, and transition to the Neurointerventional OR. Our structure with its enabling of shortened IV alteplase delivery times and faster door-to-needle (DTN) times may serve as an international model for stroke centers.

Interactions between ambient air pollutants and temperature on emergency department visits: Analysis of varying-coefficient model in Guangzhou, China

BackgroundAt present, there are few studies on the effect of short-term interactions between ambient air pollutants and temperature on cause-specific emergency department visits in China. This study aimed to explore their short-term interactions on cause-specific emergency department visits using data collected from a total of 65 public hospitals in Guangzhou city, south China. Material and methodsWe included a total of 226,443 emergency department visits which were diagnosed as neurological, respiratory and circulatory disease in Guangzhou from January 1, 2014 to December 31, 2017. Average daily concentrations of air pollutants including carbon monoxide (CO), particulate matter having a median diameter of 2.5 μm or less (PM2.5), sulfur dioxide (SO2), nitrogen dioxide (NO2) and ozone (O3) were collected from the Guangzhou Environmental Protection Bureau. We employed quasi-Poisson varying coefficient regression models to assess the interaction effects between air pollutants and daily temperature levels (DTLs) on emergency department visits for neurological, respiratory and circulatory diseases, respectively. ResultsAverage number of emergency department visits for neurological, respiratory and circulatory diseases were 92, 26 and 38, respectively. After controlling for other pollutants, meteorological factors and other time-varying confounders, we found the interactions between NO2 and the 1st DTL (3.4–17.1 °C), NO2 and the 2nd DTL (17.1–23.5 °C) for neurological emergency department visits were statistically significant, displaying a nonlinear relationship. Additionally, we found that the interactions between SO2 and the 4th DTL (27.4–31.1 °C) also had a significantly adverse effect on respiratory emergency department visits. ConclusionsOur findings provide novel evidence on SO2-by-temperature interactions, and NO2-by-temperature interactions for emergency department visits of cause-specific diseases.

Profile of Syrian Asylum-Seekers from Neurological Clinic in a Tertiary Center

Background: The humanitarian response for Syria has been largely managed either from within Syria or from neighboring countries, particularly Turkey. This study was aimed at determining the sociodemographic and clinical profiles of Syrian asylum-seekers admitted to our clinic, changes in patient number across years, and the percentage of patients on follow-ups. Methods: Syrian patients who were admitted to the neurology outpatient clinics, neurology emergency department (ED), and hospitalized in the neurology clinics were included in the study. Age, gender, number of admissions, year of admissions, chief complaints, diagnoses, and follow-up percentages of patients were recorded. Results: The total number of Syrian patients who were first admitted to our hospital and consulted from other clinics, were found to be 763 (ED: 609 [79.8%], outpatient: 134 [17.6%] consultation: 20 [2.6%]). A total of 543 (96.1%) of the patients with a neurological disorder did not come to the follow-ups even though their conditions required regular follow-ups. The most common complaints were headache (24.2%), fainting (16.1%), weakness (11.9%), and dizziness (10%). Conclusion: Most of the patients admitted to our hospital did not come to the follow-ups and information regarding their treatments could not be obtained. Even though the Republic of Turkey provided the Syrian asylum-seekers with free medical care, utilization of these resources may be limited because of socioeconomic issues.

Abstract TP113: Advanced Imaging is Associated With Longer Door to Needle Time in Candidates for Thrombolytic Treatment With No Benefit Regarding Clinical Decisions

Introduction: Growing availability of advanced imaging studies (AdIS) has resulted in increasing use of studies other than non-contrast CT (NCCT) in the evaluation of acute ischemic stroke (AIS) patients. The diagnosis of AIS is mainly clinical, and thrombolysis in patients with stroke mimics is generally considered to be safe. However, the need for diagnostic certainty and timely detection of large vessel occlusion (LVO) may incline physicians to perform more AdIS. Hypothesis: Performing pre-treatment AdIS in all patients with AIS will prolong DNT without conferring clear benefits regarding treatment decisions. Methods: We reviewed a prospective registry of AIS patients arriving at the Neurologic Emergency Department. We obtained additional information from the patients’ clinical records, and all pertinent imaging studies were reviewed to confirm diagnosis and site of arterial occlusion. Results: We analyzed 128 AIS patients treated with IV thrombolysis. Mean Door to-Needle-Time (DNT) was 83 min. Only 46% of patients were thrombolysed in the first 60 minutes after arrival. AdIS were performed in 60 patients (48%) They were equally performed among patients with NIHSS scores below and above 10 points, a possible cutoff for the presence of LVO. They also were performed equally in patients with clinically mild, and severe strokes, when the clinical diagnosis of AIS was not in doubt. On bivariate analysis, factors associated with DNT&lt;60 minutes were: female sex, posterior circulation stroke and whether only NCCT was performed. Exclusive use of NCCT was associated with a higher percentage of DNT&lt;60 minutes (59 vs 34%, p=0.005). On multivariable analysis, NCCT use was independently associated with DNT&lt;60 min (OR= 2.92, p&lt;0.007) Regarding different imaging studies, DNT means were as follows: NCCT: 69 min, CTA:79 min, CTP: 125 min, MRI 108 min (Difference between groups p=0.007). No patients were excluded from thrombolytic treatment based on AdIS results. Conclusions: The pre-thrombolysis performance of AdIS carries the risk of prolonging DNT and lowering the possibility of benefit for AIS patients. Selection of patients for specific studies and deferring AdIS until after initiating alteplase should be pursued.

Acute seizure epidemiology in a neurological emergency department.

Acute seizures in patients with epilepsy are a potential of source of neurological damage; their causes must be researched. To explore the epidemiology of acute seizure exacerbations in patients with epilepsy in a neurological emergency department in Mexico City. Descriptive prospective study of patients with a previous diagnosis of epilepsy that receive medical care in an emergency department due to acute seizures. 100 patients were analyzed between august 2016 and January 2017. 86 patients presented with focal seizures, of which 76 were focal to bilateral tonic-clonic, 2 with impaired awareness and motor onset, 3 with impaired awareness and non-motor onset, 1 without impaired awareness and motor onset, and 4 without impaired awareness and non-motor onset. 14 patients had generalized seizures with motor onset. The causes of exacerbation were as follows: 26 patients due to antiepileptic dose omission, 21 due to a unknown cause, 19 due to infection, 13 due to sleep deprivation, 3 due to stress, 3 were catamenial, 2 due to alcohol abuse and 3 due to other reasons. Of the 26 patients with dose omission, 10 were due to forgetfulness, 7 refused to comply with their prescription, 6 could not afford to buy their prescription and 3 had their prescription changed by another doctor. In Mexico, antiepileptic drug dose omission represents up to 25% of patients with acute seizure exacerbations; increased patient education on epilepsy hygiene measures may be an area of opportunity for reducing its frequency.

Stroke and TIA mimics in patients referred to a neurological emergency department by non-ambulance physicians, ambulance physicians and paramedics.

Our aim was to compare the structure and management of conditions mimicking acute cerebrovascular events (ACE) defined as stroke or transient ischaemic attack between patients referred directly to a neurological emergency department (ED) by non-ambulance physicians, ambulance physicians and paramedics. This is a retrospective study of 802 consecutive patients referred to a Polish urban neurological ED with a prehospital suspicion of ACE between January and December 2014. After proper neurological assessment, ACE was excluded in 258 (32.2%) patients. The ratios of neurological to non--neurological ACE mimics were similar across all groups (35:93 for non-ambulance physicians, 22:39 for ambulance physicians, and 28:39 for paramedics). The most frequent conditions mimicking ACE were vertigo (14.0%), headache (9.7%), seizures (7.0%), blood hypertension (7.0%), electrolyte and metabolic disturbances (5.4%), infections (4.7%) and syncope (4.3%). There were no major differences between patients with ACE-mimics referred by ambulance physicians and referred by paramedics in terms of demographic, previous medical history, extent of diagnostic workup, final diagnosis or further management (neurological admission in 42.6% and 28.4% of cases). However, the characteristics and management of ACE mimics referred by non-ambulance physicians were slightly different, including a lower need for hospital admission (neurological admission in 21.5% of cases). There seem to be no major differences in the structure, early diagnostic approach or management of ACE mimics between referrals from ambulance physicians and ambulance paramedics, which provides reassurance to healthcare systems that rely solely on paramedics. Mimics referred by non ambulance physicians appear different in structure and are less resource-consuming.

Diagnosing cerebral ischemia with door-to-thrombolysis times below 20 minutes.

To clarify diagnostic accuracy and consequences of misdiagnosis in the admission evaluation of stroke-code patients in a neurologic emergency department with less than 20-minute door-to-thrombolysis times. Accuracy of admission diagnostics was studied in an observational cohort of 1,015 stroke-code patients arriving by ambulance as candidates for recanalization therapy between May 2013 and November 2015. Immediate admission evaluation was performed by a stroke neurologist or a neurology resident with dedicated stroke training, primarily utilizing CT-based imaging. The rate of correct admission diagnosis was 91.1% (604/663) for acute cerebral ischemia (ischemic stroke/TIA), 99.2% (117/118) for hemorrhagic stroke, and 61.5% (144/234) for stroke mimics. Of the 150 (14.8%) misdiagnosed patients, 135 (90.0%) had no acute findings on initial imaging and 100 (67.6%) presented with NIH Stroke Scale score 0 to 2. Misdiagnosis altered medical management in 70 cases, including administration of unnecessary treatments (thrombolysis n = 13, other n = 24), omission of thrombolysis (n = 5), delays to specific treatments of stroke mimics (n = 13, median 56 [31-93] hours), and delays to antiplatelet medication (n = 14, median 1 [1-2] day). Misdiagnosis extended emergency department stay (median 6.6 [4.7-10.4] vs 5.8 [3.7-9.2] hours; p = 0.001) and led to unnecessary stroke unit stay (n = 10). Detailed review revealed 8 cases (0.8%) in which misdiagnosis was possible or likely to have worsened outcomes, but no death occurred as a result of misdiagnosis. Our findings support the safety of highly optimized door-to-needle times, built on thorough training in a large-volume, centralized stroke service with long-standing experience. Augmented imaging and front-loaded specialist engagement are warranted to further improve rapid stroke diagnostics.

Short-term associations of ambient air pollution and cause-specific emergency department visits in Guangzhou, China

BackgroundEvidence of association of ambient air pollution with cause-specific emergency department visits in China is still limited. This study aimed to investigate short-term associations between exposures to air pollutants and daily cause-specific emergency department visits using a large-scale multicenter database involving a total of 65 sentinel hospitals in Guangzhou, the most densely-populated city in south China, during 2013–2015. Material and methodsWe obtained data on 162,771 emergency department visits from 65 hospitals from the Emergency Medical Command Center in Guangzhou between January 1, 2013 and December 31, 2015. Daily air pollution data on particulate matter (PM) of aerodynamic diameter<10 and 2.5μm (PM10, and PM2.5, respectively), sulfur dioxide (SO2), nitrogen dioxide (NO2) and ozone (O3) were collected from the Daily Quality Report of the Guangzhou Environmental Protection Bureau during the study period. Visits for neurologic, respiratory and circulatory diseases were assessed in relation to air pollutants using Poisson generalized additive models. ResultsMean daily number of emergency department visits for neurologic, respiratory and circulatory diseases was 89, 24 and 35, respectively. After adjustment for other pollutants (PM2.5, PM10, NO2 and O3), meteorological factors and time-varying confounders, a 7.98-μg/m3 (interquartile range) increment in 2-day moving average of same-day and previous-day SO2 concentrations was associated with the statistically significant increase of 4.89% (95% confidence interval: 2.86, 6.95) in neurologic emergency department visits; elevation in SO2 level (per 7.98μg/m3) was linked to a 5.19% (95% confidence interval: 2.03, 8.44) increase in circulatory emergency department visits. Most positive links were seen during the cold season. ConclusionsThe results of this study contribute to the evidence of the significant associations between SO2 and specific neurologic and circulatory conditions, and also provide insight into the planning of clinical services and emergency contingency response for air pollution exposures in Guangzhou.

Prehospital pathways of occipital stroke patients with mainly visual symptoms.

Occipital ischemic strokes typically cause homonymous visual field defects, for which means of rehabilitation are limited. Intravenous thrombolysis is increasingly and successfully used for their acute treatment. However, recognition of strokes presenting with mainly visual field defects is challenging for both patients and healthcare professionals. We studied prehospital pathways of occipital stroke patients with mainly visual symptoms to define obstacles in their early recognition. This observational, retrospective, registry-based study comprises occipital stroke patients with isolated visual symptoms treated at the neurological emergency department of Helsinki University Central Hospital in 2010-2015. We analyzed their prehospital pathways, including time from symptom onset to admission at the neurological emergency department (ODT), the number of points of care, the percentage of patients with ODT≤4.5hours, and factors associated with delay. Among 245 patients, only 20.8% arrived within 4.5hours and 6.5% received IV thrombolysis. Delayed arrival was most often due to patients' late contact to health care. Of the patients, 27.3% arrived through at least two points of care, and differential diagnostics to ophthalmologic disorders proved particularly challenging. ODT≤4.5hours was associated with EMS utilization, direct arrival, and atrial fibrillation; a visit at an ophthalmologist and initial misdiagnosis were associated with ODT>4.5hours. After multivariable analysis, only direct arrival predicted ODT≤4.5hours. Occipital stroke patients with visual symptoms contact health care late, are inadequately recognized, and present with complex prehospital pathways. Consequently, they are often ineligible for IV thrombolysis. This presents a missed opportunity for preventing permanent visual field defects.

Online survey of the organizational structures of emergency neurology in Germany

In 2007, the first poll among neurologists provided some insight into the organizational structures of emergency neurology in Germany. Given that emergency neurology as well as emergency medicine in general have undergone substantial changes during the last decade, the subcommittee Neurological Emergency Medicine of the German Neurological Society conducted afollow-up study to explore current structures supporting neurological emergency medicine in German neurological hospitals. Between July and September 2016, an online questionnaire was e‑mailed to 675 neurologists in institutions participating in in-patient neurological care. Of these, some 32% (university hospitals 49%) answered. Neurological patients represent 12-16% and hence asignificant proportion of emergency patients. The fraction of in-patients admitted to hospitals via emergency departments amounted to 78% (median) in general hospitals and 52% in university hospitals. Most emergency departments are organized as an interdisciplinary structure combining conservative with surgical disciplines frequently led by an independent department head. Neurology departments employ rather diverse strategies to organize neurological emergency care. Also, the way emergency patients are assigned to different disciplines varied largely. Currently, neurological patients represent arather growing fraction of patients in emergency departments. An increasing proportion of neurology in-patients enter the hospital via emergency departments. Neurology departments in Germany face increasing challenges to cope with large numbers of neurological emergency patients. While most of the participating neurologists indicated suffering predominantly from scarce personal resources both in neurology and neuroradiology, an independent neurological emergency department was not considered an option.

Abstract TP229: Change Takes Time: EMS as the Spark Plug for Faster Acute Ischemic Stroke Care

Introduction: It is well documented that a Prehospital Stroke Alert (PHSA) protocol leads to decreased treatment times for stroke patients. Outcomes measured typically include Door to Physician (DTP), Door to CT (DTCT), and Door to Needle (DNT) times. Our comprehensive stroke center’s PHSA system has been in place since 2012. This study evaluates 3 specific endpoints. First, Emergency Medical Services (EMS) improve their recognition of stroke symptoms as they gain experience with PHSA. Second, a PHSA protocol decreases intervention times of DTP, DTCT, and DNT over a study period of 3 years. Third, when patients present to our Neurologic Emergency Department (Neuro ED) as a PHSA, rather than a non-PHSA, the intervention times are markedly decreased, and acute ischemic stroke care is significantly expedited. Methods: A retrospective chart review was conducted for patients who presented to our hospital with an admitting diagnosis of stroke from 2012-2014. Patients were screened for presentation to the Neuro ED and further stratified based on whether a PHSA was called. PHSA was called if EMS deemed the patient’s Cincinnati Stroke Scale score as positive, and symptom onset was within 6 hours. We recorded DTCT, DTP, and DTN times over the years for all patients meeting these inclusion criteria. Results: Three hundred and five patients with an admission diagnosis of stroke were seen in the Neuro ED (Hours are 0700-1800, 7 days a week) from 2012 to 2014, 128 of which presented as PHSAs. EMS responders accurately diagnosed stroke in 82% of cases. Previously, EMS assessment of stroke was accurate only 66% of the time. PHSA patients had decreased DTP, DTCT, and DTN times over the 3 year period. When comparing the PHSA group to non-PHSA group, statistically significant differences were found in DTP and DTCT times within each year (p≤0.0001). Discussion: In conclusion, gaining experience with a PHSA protocol did in fact lead to EMS better recognizing stroke symptoms, reduction in the times of delivery of care for acute ischemic stroke patients over the years 2012-2014, and a markedly statistically significant difference in intervention times if patients were seen as a PHSA as opposed to a non-PHSA.

Conversion disorder in a neurological emergency department: Restrospective series

Objective: To observe the conversion disorder in a neurological emergency department. Methods: It is common that the initial approach to this patients include the use of various diagnostic exams. In this series we reviewed 94 patients that arrived a neurological emergency room in a 3 year period. Results: 72 patients were females (76%), and the initial presumptive diagnosis were: neurovascular syndrome in 36 patients (38.3%), convulsive disorder in 20 patients (21.28%), and conversive disorder in 8 patients (8.51%). 82 patients had motor symptoms and 61 sensitive symptoms. 88 patients (93%) required neuroimaging studies, 77 (81%) patients underwent through basic biochemical panels. Other tests performed were: electroencephalogram in 12 patients (12.77%), electromyography in 11 patients (11.7%), lumbar punction in 8 patients (8.04%) and regarding the medical consult in the care of these patients 11 were evaluated by 1 specialists, 35 (37.2%) by 2 different specialties, 42 (44.63%) patients required evaluation by 3, and 6 patients (6.38%) required evaluation by 4 different specialties. Conclusions: Based on this data, we conclude that conversion disorders require a lot of resources in the emergency room and that the similarities with neurological diseases demands a complete workup including expensive diagnostic tools. However, this patients can be discharged safely without requiring hospitalization.