Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials

Abstract

A larger therapeutic window for stroke treatment requires a significant change in the organization of emergency services, avoiding the increase in number of imaging exams and indirectly the time to treatment. Objective: To highlight the relation between faster clinical evaluation and stroke over-suspicion and consequently excessive imaging acquisition. To identify predictors of ischemic stroke and stroke mimics (SM), aiming for better patient selection for comprehensive neuroimaging and reperfusion therapies. Methods: Retrospective, cohort, observational, single-center study that reviewed all consecutive files of patients presenting with acute neurological symptoms who underwent CT scan or MRI from July 1, 2016 to July 1, 2017. Results: 736 patient files were reviewed. 385 patients (52.3%) presented with confirmed acute ischemic infarct, 93 (12.6%) had another brain lesion mimicking acute ischemia, and 258 (35.1%) had normal imaging. Acute stroke was more frequent in elderly patients with atrial fibrillation, arterial hypertension, or dysarthria or right motor impairment. Stroke mimic was associated with female patients with low vascular risk factors, low NIHSS, and patients with decreased level of consciousness or symptoms suggestive of posterior circulation. Discussion: 47.7% of all patients seen at the stroke unit did not have acute stroke lesions. Clinical assessment data have been used to provide indicators of acute stroke and stroke mimic patients, and symptoms corresponding to acute stroke and stroke mimic seem to be similar in the literature. Conclusion: Considering that the number of patients admitted for stroke treatment will increase even further with a larger therapeutic window for mechanical thrombectomy and for thrombolysis, a diagnostic decision-making algorithm for stroke patients is required in order to reinforce the suspicion of stroke indicating an urgent MRI.

Ischemic stroke mimics: A comprehensive review

“…SM patients had significantly lower NIHSS (4.99 ± 5.65 vs. 8.06 ± 6.37, p < 0.001 /11, 14, 15, 19, 20-22, 24, 26, 28, 30, 34, 37, 41, 42, 45, 47 [11,17,19,28,33,34,36,49] and more of them were able to walk comparing to ischemic stroke patients: 51.38% (56/109) vs. 37.5% (84/224) (p = 0.016) although it was based on the results of one study [11]. Glasgow Coma Scale (GCS) < 15 was 91.9% (1152/1267) in ischemic stroke and 88.8% (688/775) in SM patients (p = 0.43) [11,19,39,62].…”

“…Hypertension 66.8% (20074/30035) vs. 41.1% (3434/8347) [11,14,15,19,20,21,23,24,28,[30][31][32][33][34]37,38,[40][41][42]47,48,50,52,23,[55][56][57][58][59]61,64,65,67,68,70,71], dyslipidaemia 38% (9891/26005) vs. 23.6% (1585/6717) [14,15,19,20,23,28,[32][33][34]37,40,41,48,50,52,53,…”

Differences in Characteristics and Ambulance Pathway Adherence Between Strokes and Mimics Presenting to a Large UK Centralized Hyper Acute Stroke Unit (HASU)

“…For stroke, the maxim that “time is brain” emphasizes the importance of early identification and rapid transportation to a HASU, with immediate access to the full range of hyperacute stroke treatment. Yet, large volumes of mimics can result in delayed care, particularly in centralized services, and reduced resource availability for those that are experiencing a stroke ( 11 , 12 ). Additionally, prehospital stroke care has been shown to affect in-hospital care processes, such as door-to-scan times ( 13 , 14 ).…”

Identifying the Stroke Mimics

“…6 Table 1 shows the multiple stroke mimics that have been reported in the literature. [12][13][14]15,16 Future studies should incorporate broader differential and detailed workup.…”