Ischemic stroke is a leading cause of morbidity and mortality in the United States. Prompt diagnosis of stroke is crucial to timely and adequate management and delays in care can lead to increased morbidity and mortality. Patients who present with altered mental status and coma have a higher likelihood of being misdiagnosed. In this study, we examined the relationship between disorders of consciousness (DOC) and time to stroke treatment.

We identified 264 patients with ischemic stroke who presented to a Montefiore emergency department in 2019. Patients were identified using ICD-10 codes and verified with radiographic diagnosis. The presence of a DOC was identified using ER diagnosis and mention of terms in the electronic medical record including “altered mental status,” “encephalopathy” and “obtunded”. Outcome measures included time to CT, MRI, Neurology consult and antiplatelet therapy. We also measured whether antiplatelet therapy was given before or after 24 hours. Variables were evaluated using independent samples t-tests and chi-squared tests. 

For the full cohort, mean time to CT was 1.26 hours, MRI was 14.05 hours, neurology consult was 4.34 hours, and antiplatelet therapy was 14.16 hours from initial presentation. For patients with DOC, mean time to CT was 1.44 hours (t=-.668, p=.485), MRI was 23.13 hours (t =-5.426, p=<.001*), neurology consult was 5.82 hours (t=-1.819, p=.025*) and antiplatelet therapy was 16.87 hours (t=-1.829, p=.189). Patients with an emergency room diagnosis of “altered mental status” were more likely to receive antiplatelet therapy after 24 hours than patients with any other diagnosis (χ²=5.024, p=.025*).

DOC are associated with delays in stroke treatment and deviations from evidence-based guidelines. Improving early stroke diagnosis should lead to earlier treatment and possibly improved outcomes.