Thrombolysis to stroke mimics in telestroke

Abstract

Stroke mimics are patients diagnosed initially with stroke who finally receive a different diagnosis, such as seizure, conversion disorder or encephelopathy. We compared the number of stroke mimics receiving thrombolytic therapy via a telestroke network and via a conventional primary stroke centre. We reviewed the data on all patients who received intravenous t-PA through the ARSAVES statewide telestroke network or at the University of Arkansas for Medical Sciences (UAMS) stroke centre between November 2008 and January 2012. During the study period there were 252 patients (46 UAMS, 206 ARSAVES). Of the 206 telestroke patients, 141 patients (68%) were transferred to the UAMS and were examined there by a vascular neurologist where a diagnosis of stroke or stroke mimic was made; 65 patients (32%) stayed at the peripheral site and were excluded from the present study. Of the 189 study patients, 3-month outcome data were available on 166 (89%), 43 from UAMS (94%) and 123 from ARSAVES (87%). The mean door to needle time was significantly shorter at the UAMS (72 min vs. 91 min, P = 0.001). However, the percentage of good outcomes was similar in both groups (70% vs. 58%, P = 0.21) and both groups had similar total time from symptom onset to treatment (154 min vs. 156 min, P = 0.81) and similar baseline characteristics. The percentage of stroke mimics was similar in the two groups: UAMS 4.3% and ARSAVES 7.8% (P = 0.53). Although making a diagnosis of stroke mimic may be challenging on face-to-face encounter, our study shows that this challenge does not increase if telemedicine is used instead. Larger prospective studies are now required to confirm the findings of our study.

Ischemic stroke mimics: A comprehensive review

“…Confusion could be detected in 11.2% (87/775) in SM and 8.9% (115/1284) in ischemic stroke patients (p = 0.09) [11,14,16,34,38,44,59,70]. No signs of stroke on physical examination could be found 33.7% (131/389) in SM and 10.5% (36/343) in ischemic stroke patients (p < 0.001) (Fig.…”

Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

“…Given the time pressures of decision making in ischemic stroke and the similarity of presentation for ischemic stroke and many stroke mimics, treatment rates of stroke mimics are 6% to 16%. 103,106,107 Reports vary as to whether this fraction is higher or the same in drip-and-ship paradigms 103 for in-person treatments compared with patients treated by telestroke. 107 Collecting outcome data on treated stroke mimics by the stroke center can be done more easily when patients are transferred and follow-up imaging can confirm or exclude infarction, but this needs to be a collaborative effort by both the originating and distant sites.…”

“…103,106,107 Reports vary as to whether this fraction is higher or the same in drip-and-ship paradigms 103 for in-person treatments compared with patients treated by telestroke. 107 Collecting outcome data on treated stroke mimics by the stroke center can be done more easily when patients are transferred and follow-up imaging can confirm or exclude infarction, but this needs to be a collaborative effort by both the originating and distant sites. Although current evidence suggests that stroke mimics are not exposed to excessive risk by the use of intravenous tPA, 108 it is an expensive therapy (including drug cost, 24 hours of monitoring in an intensive care unit, follow-up head imaging, and potential ground or air transport to a stroke center).…”

Post t-PA transfer to hub improves outcome of moderate to severe ischemic stroke patients

“…3,4 Furthermore, not only did telestroke increase the utilization of thrombolytic therapy, it did so without negatively impacting outcome, risk of hemorrhage, and door to needle (DTN) time, thus providing a real alternative in hospitals where 24-hour emergency neurology services are unavailable. 5,6 Large networks like TEMPiS (Telemedical Project for Integrative Stroke Care) in Southeast Bavaria, Germany are offering high quality telestroke care at a large scale in rural areas. TEMPiS is registering a median DTN time of 40 minutes.…”