Safety of thrombolysis in stroke mimics: an observational cohort study from an urban teaching hospital in Sweden

Abstract

ObjectivesAcute stroke management has changed dramatically over the recent years, where a timely assessment is driven by the expanding treatment options of acute ischaemic stroke. This increases the risk in treating non-stroke patients (stroke mimics) with a possibly hazardous intravenous thrombolysis treatment (IVT).SettingPatients of the thrombolysis registry of Södersjukhuset AB, a secondary health centre in Stockholm, were retrospectively studied to determine complications and outcome after IVT in strokes and stroke mimics.ParticipantsConsecutively, 674 recruited patients from 1 January 2008 to 1 December 2013 were analysed regarding demographics and outcome at 3 months after onset of symptoms.ResultsIschaemic stroke was confirmed in 625 patients (93%), and 48 patients (7%) were stroke mimics. Patients with strokes were older than stroke mimics 72 (IQR: 64–81) vs 54 years (IQR 40–67), p<0.0001. Antihypertensive and antithrombotic treatment were more common in patients with stroke (p<0.0001 and p=0.006, respectively). National Institute of Health Stroke Scale did not differ at time of presentation. Excellent outcome defined as modified Rankin Scale score 0–1, at 3 months, was less common in stroke than in stroke mimics (50% vs 87.5%, p<0.0001). No stroke mimic had a symptomatic intracerebral haemorrhage. Age of less than 40 years may be a predictor for a patient to be a stroke mimic (OR: 8.7, 95% CI: 3.2 to 24.0, p<0.0001).ConclusionsStroke mimics receiving IVT had a more favourable outcome compared with patients with stroke, and showed no haemorrhagic complications. Age below 40 years may be a predictor for stroke mimics.

Intravenous thrombolysis in stroke mimics: results from the SITS International Stroke Thrombolysis Register

“…The 3-month outcome data were missing in 14% of cases. Nevertheless, our results on functional outcome and death in patients with SM are consistent with previous studies [5,8,22].…”

Ischemic stroke with a preceding Trans ischemic attack(TIA) less than 24 hours and thrombolytic therapy

“…With an increased capability of accurately diagnosing a migraine attack, it is possible that a comprehensive clinical evaluation provided an accurate diagnosis of migraine with existing history in the TIA-ischemic stroke patients in this study. Even when a definitive diagnosis is not possible, the evidence of rtPA safety in scientific literature [45][46][47][48][49] supports its administration, as shown in the current study.…”

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

“…Therefore it is reasonable to approach them in the acute phase in a similar manner to patients with suspected stroke, combining those two groups into suspected ACE [6]. As the diagnosis of the ACE is mainly based on clinical symptoms, it may sometimes lead to initiation of intravenous thrombolysis in a non-stroke patient [1,2,12,17]. For that reason, some authors propose MR as the first choice imaging modality in hyperacute and acute stages to actually visualise the responsible ischaemic lesion [8,9,18,19].…”

“…Previous studies have shown that stroke mimics may account for as much as half of all suspected strokes, with a very wide range (2% to 47%) depending on the setting and methodology [2,[7][8][9][10][11]. More importantly, up to 10% of patients treated with intravenous thrombolysis may actually suffer from a condition other than ischaemic stroke [2,12]. Therefore, clinicians should be aware of the most common stroke mimics that need to be addressed in the acute diagnostic workup at the ED.…”