Intravenous Tissue Plasminogen Activator in Stroke Mimics

Abstract

Background: The necessity for rapid evaluation and treatment of acute ischemic stroke with intravenous tPA (tissue-type plasminogen activator) may increase the risk of administrating tPA to patients presenting with noncerebrovascular conditions that closely resemble stroke (stroke mimics). However, there are limited data on thrombolysis safety in stroke mimics. Methods and Results: Using data from the Get With The Guidelines–Stroke Registry, we identified 72 582 patients with suspected ischemic stroke treated with tPA from 485 US hospitals between January 2010 and December 2017. We documented the use of tPA in stroke mimics, defined as patients who present with stroke-like symptoms, but after workup are determined not to have suffered from a stroke or transient ischemic attack, and compared characteristics and outcomes in stroke mimics versus those with ischemic stroke. Overall, 3.5% of tPA treatments were given to stroke mimics. Among them, 38.2% had a final nonstroke diagnoses of migraine, functional disorder, seizure, and electrolyte or metabolic imbalance. Compared with tPA-treated true ischemic strokes, tPA-treated mimics were younger (median 54 versus 71 years), had a less severe National Institute of Health Stroke Scale (median 6 versus 8), and a lower prevalence of cardiovascular risk factors, except for a higher prevalence of prior stroke/transient ischemic attack (31.3% versus 26.1%, all P <0.001). The rate of symptomatic intracranial hemorrhage was lower in stroke mimics (0.4%) as compared with 3.5% in ischemic strokes (adjusted odds ratio, 0.29; 95% CI, 0.17–0.50). In-hospital mortality rate was significantly lower in stroke mimics (0.8% versus 6.2%, adjusted odds ratio, 0.31; 95% CI, 0.20–0.49). Patients with stroke mimics were more likely to be discharged to home (83.8% versus 49.3%, adjusted odds ratio, 2.97; 95% CI, 2.59–3.42) and to ambulate independently at discharge (78.6% versus 50.6%, adjusted odds ratio, 1.86; 95% CI, 1.61–2.14). Conclusions: In this large cohort of patients treated with tPA, relatively few patients who received tPA for presumed stroke were ultimately not diagnosed with a stroke or transient ischemic attack. The complication rates associated with tPA in stroke mimics were low. Despite the potential risk of administering tPA to stroke mimics, opportunity remains for continued improvement in the rapid and accurate diagnosis and treatment of ischemic stroke.

External Validation of Stroke Mimic Prediction Scales in the Emergency Department

“…Although the low stroke mimic rate is likely attributable to our study design of including only patients with IVT, even in a randomised controlled trial for thrombolysis, stroke mimic rates can be as high as 16.6% [19]. Nevertheless, our finding is comparable with other studies which only included patients who had IVT, the stroke mimic rate was 3.5-4.1% [5,20]. The majority of stroke mimics in our study was diagnosed with functional weakness, at a high rate of 41.2%.…”

“…Unfortunately, this particular patient required an urgent surgical evacuation of an epidural hematoma. Although hemorrhagic complication rate from 10 IVT in stroke mimics has been reported to be low [5,20], these complications, when it occurs, may be life threatening and require urgent surgical interventions. Therefore, preventing unwarranted IVT in these numerous stroke mimics is essential and remain an unmet clinical need.…”

“…Accurate diagnosis of ischemic stroke is critical, as IVT in stroke mimics may result in a small, but significant, life-threatening risk of intracerebral haemorrhage, without any benefit. [4,5] Despite the availability of a multitude of radiological investigations to exclude stroke mimics, the diagnosis of stroke remains a clinical diagnosis. Emergent use of non-contrast computed tomography (NCCT) head in patients with stroke-like symptoms is primarily to exclude intracerebral hemorrhage [1] and not to confirm the presence of an ischemic stroke.…”

Identifying the Stroke Mimics

“…Ahmed et al studied 72,582 patients from 485 US hospitals with suspected ischemic stroke who received alteplase. 9 Among all the recruited patients, only 3.5% of stroke mimics received alteplase. Intracranial hemorrhage and in-hospital mortality were 0.4%, and 0.8% in the mimics compared to 3.5% and 6.2% of patients with ischemic stroke.…”

“…Intracranial hemorrhage and in-hospital mortality were 0.4%, and 0.8% in the mimics compared to 3.5% and 6.2% of patients with ischemic stroke. 9 , 10 …”