Stroke Mimics

Ahamad Hassan Consultant Neurologist & Stroke Physician Leeds Teaching Hospitals

Acute stroke is a treatable medical emergency

Alteplase given within 3 hours improves functional outcome without increase in mortality. Stroke must be recognised quickly and reliably by paramedics or emergency room staff

Distinguishing stroke from mimics

Diagnostic inaccuracy approx 25% Similar error rate for trained paramedics, A+E and GPs Risk of patient being inappropriately thrombolysed Risk of patient not being given correct treatment promptly

Azzimondi et al Stroke 1997 Harbison et al Stroke 2003

Pathway activation by A+E

Age 8% TPA 17% >3hrs 4%

Other Exclusion 4%

No Time Line 10%

Too Mild/TIA 15%

Non Stroke 23% Too severe 4% ICH/SAH 15%

101 cases assessed in A+E, LGI 1/7/2007-31/10/2008

Causes of Stroke Mimics (n=109)

Condition Seizure Sepsis Toxic/metabolic SOL Syncope Delirium Vestibular Mononeuropathy Functional Dementia Migraine % 21.1 12.8 11.0 9.2 9.2 6.4 6.4 5.5 5.5 3.7 2.8 <6hrs 29.0 9.7 9.7 4.8 14.5 4.8 4.8 6.5 6.5 3.2 3.2 >6hrs 10.6 17.0 12.8 14.9 2.1 8.5 8.5 4.3 4.3 4.3 4.3
Hand et al Stroke 2006

Causes of Stroke Mimics (n=109)

Condition Seizure Sepsis Toxic/metabolic SOL Syncope Delirium Vestibular Mononeuropathy Functional Dementia Migraine % 21.1 12.8 11.0 9.2 9.2 6.4 6.4 5.5 5.5 3.7 2.8 <6hrs 29.0 9.7 9.7 4.8 14.5 4.8 4.8 6.5 6.5 3.2 3.2 >6hrs 10.6 17.0 12.8 14.9 2.1 8.5 8.5 4.3 4.3 4.3 4.3

Rapid, reliable diagnosis of stroke critical for safe, effective delivery of alteplase. Stroke recognition tools can facilitate Incorporated into hyperacute stroke protocols Comprise key clinical features which have a high predictive value for stroke

Used widely by paramedics Public educational campaigns Any 1 of 3 symptoms Rapid. Quick screening tool Sensitivity/Specificity 80%

Rosier scale
Used in Emergency room 7 point scoring system Higher sensitivity 93% Specificity= 83%

Nor et al , Lancet Neurol 2005

Tools make things easier but not infallible.

Prospective testing ..
False +
Functional Hemiplegic/complex migraine Seizures (Todds Paresis)

Safety of TPA in Stroke Mimics

2 large series >500 patients Rx Stroke Misdiagnosis rate =10-14% No cases of SICH 90% functionally independent

Chernyshev et al 2010, Tsivgoulis 2011

False -ve

Posterior circulation stroke

Thalamic infarct [lacunar]

Recognition tools
Useful for rapid screening and diagnosis Neurological History/Exam remains essential Fall back position in grey cases Some Tips

NIH stroke scale

11 item (42 point scale) Conscious level Eye movements Vision Motor power in limbs/face Co-ordination Sensation Language Articulation Inattention

NIH stroke scale

Quantify stroke severity in a consistent way Objectively scoring number/magnitude focal deficits
Predicts lesion size and stroke outcome Useful in determining suitability for thrombolysis Post thrombolysis monitoring ? Role in stroke diagnosis

Proportion brain attacks attributable to stroke or mimic subdivided by NIHSS score

Hand et al Stroke 2006

Logistic regression model for predicting diagnosis of brain attack

OR Known cognitive impairment Exact onset determined Definite focal symptoms Abnormal vascular findings NIHSS 1-4 5-10 >10 Signs localise to either left or right OCSP classification possible 1.92 3.14 7.23 2.03 5.09 (0.70-5.23) (1.03-9.65) (2.18-24.05) (0.92-4.46) (2.42-10.70) 0.33 2.59 7.21 2.54 95%CI 0.14-0.76 (1.30-5.15) (2.48-20.93) (1.28-5.07)

Hyperacute radiology for stroke mimic

Non contrast CT widely available Limited role, often normal Early infarct signs confirm clinical suspicion of stroke Rarely non stroke neurological mimics seen e.g. SOL Rarely clarifies clinical picture, if diagnostic confusion from outset (advanced imaging more useful)

Stroke or Mimic: Radiology

Hyperdensity MCA

Hyperdensity distal MCA

Hyperdensity ICA

Excellent interobserver reliability. Low sensitivity, very high specificity 95-100%

(If definitely present confident that not stroke mimic)

Perfusion CT

CT-A

MR-DWI

Advanced Imaging

Bilateral Carotid Occlusion

Take Home Messages

Stroke recognition tools allow rapid detection of stroke with very good sensitivity and specificity Approx 20% strokes referred for hyperacute treatment will be mimics 10% of strokes will be chameleons, hard to spot Key discriminators from history and examination can improve diagnostic accuracy Neuroimaging can play a useful secondary role