Circulating Metabolites Differentiate Acute Ischemic Stroke from Stroke Mimics

Background/Purpose: Intravenous Alteplase (t-PA) improves outcome in patients with acute ischemic stroke. Of those who recover fully, some may not have had ischemia. We analyzed the frequency and post-treatment outcomes of patients with no imaging evidence of stroke and aimed to delineate the frequency of strokes with full recovery from that of stroke mimics treated with t-PA. Methods: We included all adult stroke patients treated with IV t-PA within 3 hours of stroke onset from the UCSD SPOTRIAS database. Group 1: Patients with neuroimaging evidence of acute stroke (IPS); Group 2: no neuroimaging evidence of acute stroke (INS). All diagnoses were established by an independent adjudicating body. We reviewed medical records, neuroimaging, and compared discharge diagnosis, 90-day mRS, and incidence of intracranial hemorrhage. We adjusted for age, admission NIHSS, and pre-stroke mRS in multivariable models. Results: We identified 61patients with IPS and 25 with INS, with similar baseline characteristics, except for baseline NIHSS (IPS 13.4±8.2, INS 8.4±5.9, p=0.007) and incidence of cardiac arrhythmias (IPS 36.1%, INS 4.0%, p=0.002). Adjusted for age and baseline NIHSS, we found no difference in outcome. ICH was found in 23% of the IPS patients and was symptomatic in 4.9%. None of the INS patients had ICH. Conclusions: Radiologic evidence of acute ischemic stroke was absent in 10.5% of the 86 patients in the UCSD SPOTRIAS database who were treated with t-PA and given a clinical diagnosis of acute ischemic stroke on adjudicating body review at discharge. The majority (64%) of imaging negative stroke patients in our study ultimately received the clinical diagnosis of acute stroke. No significant difference in outcomes (mRS) was found between imaging negative and imaging positive stroke code patients, aside from the increased ICH frequency in imaging positive patients. This lack of outcome difference emphasizes that while imaging plays an important role as a surrogate marker in determining the diagnosis, a detailed clinical evaluation is essential in the correct treatment of acute ischemic stroke. Imaging negative stroke patients are common and future larger scale prospective data is required to analyze the true frequency of stroke mimics versus imaging negative stroke.

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Multimodal CT to Differentiate Acute Ischemic Stroke From Stroke Mimics

The Neurohospitalist ◽

10.1177/1941874412439582 ◽

2012 ◽

Vol 2 (2) ◽

pp. 60-61

Author(s):

Warren Vincent Carrigan ◽

Kevin Barrett ◽

William David Freeman ◽

Nicole Avalon

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Mimics ◽

Multimodal Ct

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External Validation of Stroke Mimic Prediction Scales in the Emergency Department

10.21203/rs.3.rs-22178/v1 ◽

2020 ◽

Author(s):

Tian Ming Tu ◽

Guan Zhong Tan ◽

Seyed Ehsan Saffari ◽

Chee Keong Wee ◽

David Jeremiah Ming Siang Chee ◽

...

Keyword(s):

Ischemic Stroke ◽

Decision Tree ◽

Acute Ischemic Stroke ◽

Univariate Analysis ◽

Receiver Operating Curve ◽

Emergency Setting ◽

Predictive Values ◽

Stroke Mimics ◽

Prediction Tools ◽

Stroke Mimic

Abstract Background Acute ischemic stroke is a time-sensitive emergency where accurate diagnosis is required promptly. Due to time pressures, stroke mimics, whom present with similar signs and symptoms as acute ischemic stroke, pose a diagnostic challenge to the emergency physician. With limited access to investigative tools, clinical prediction tools, based only on clinical features, may be useful to identify stroke mimics. We aim to externally validate the performance of 4 stroke mimic prediction scales and aim to derive a novel decision tree, to improve identification of stroke mimics. Methods We performed a retrospective cross-sectional study at a primary stroke centre, served by a telestroke hub. We included consecutive patients whom were administered intravenous thrombolysis for suspected acute ischemic stroke from January 2015 to October 2017. Four stroke mimic prediction tools (FABS, simplified FABS, Telestroke Mimic Score and Khan Score) were rated simultaneously, using only clinical information prior to administration of thrombolysis. The final diagnosis was ascertained by an independent stroke neurologist. Area under receiver operating curve (AUROC) analysis was performed. A classification tree analysis was also conducted using variables which were found to be significant in the univariate analysis. Results Telestroke Mimic Score had the highest discrimination for stroke mimics among the 4 scores tested (AUROC = 0.75, 95% CI = 0.63–0.87), although it was not statistically significantly better. Telestroke Mimic Score had the highest sensitivity (91.3%), while Khan score had the highest specificity (88.2%). All 4 scores had high positive predictive value (88.1–97.5%) and low negative predictive values (4.7–32.3%). A novel decision tree, using only age, presence of migraine and psychiatric history, had a higher prediction performance (AUROC = 0.80). Conclusion Four tested stroke mimic prediction scales performed similarly well to identify stroke mimics in the emergency setting. A novel decision tree may improve the identification of stroke mimics.

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Stroke Mimics: An Important Source of Bias in Acute Ischemic Stroke Research

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2019.06.019 ◽

2019 ◽

Vol 28 (9) ◽

pp. 2475-2480

Author(s):

Ravi Garg ◽

Megan A. Rech ◽

Michael Schneck

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Mimics ◽

Stroke Research

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Can perfusion CT unmask postictal stroke mimics?

Neurology ◽

10.1212/wnl.0000000000006501 ◽

2018 ◽

Vol 91 (20) ◽

pp. e1918-e1927 ◽

Cited By ~ 9

Author(s):

Margot G.A. Van Cauwenberge ◽

Sven Dekeyzer ◽

Omid Nikoubashman ◽

Manuel Dafotakis ◽

Martin Wiesmann

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Predictive Value ◽

Diagnostic Algorithm ◽

Epileptic Seizures ◽

Diagnostic Value ◽

Perfusion Ct ◽

Retrospective Case ◽

Stroke Mimics ◽

Neurologic Deficits

ObjectiveTo study the diagnostic value of volume perfusion CT (VPCT) in patients with transient focal neurologic deficits following and during epileptic seizures, that mimic symptoms of stroke.MethodsA retrospective case-control study was performed on 159 patients who presented with a seizure and received an emergency VPCT within the first 3.5 hours of admission, after being misjudged to have an acute stroke. The reference test was a clinical-based, EEG-supported diagnostic algorithm for seizure.ResultsWe included 133 patients: 94 stroke-mimicking cases with postictal focal neurologic deficits (“Todd phenomenon,” n = 67) or ongoing seizure on hospital admission (“ictal patients,” n = 27), and 39 postictal controls without focal neurologic deficits. Patients with Todd phenomenon showed normal perfusion (64%), hypoperfusion (21%), and hyperperfusion (14%) on early VPCT. Ictal patients displayed more hyperperfusion compared to postictal patients (p = 0.015). Test sensitivity of hyperperfusion for ictal patients is 38% (95% confidence interval [CI] 20.7%–57.7%), specificity 86% (95% CI 77.3%–91.7%), positive predictive value is 42% (95% CI 27.5%–58.7%), and the negative predictive value 83% (95% CI 78.6%–86.9%). A cortical distribution was seen in all hyperperfusion scans, compared to a cortico-subcortical pattern in hypoperfusion (p < 0.001). A history of complex focal seizure and age were associated with hyperperfusion (p = 0.046 and 0.038, respectively).ConclusionVPCT can differentiate ictal stroke mimics with hyperperfusion from acute ischemic stroke, but not postictal patients who display perfusion patterns overlapping with ischemic stroke.Classification of evidenceThis study provides Class IV evidence that VPCT accurately differentiates ictal stroke mimics from acute ischemic stroke.

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Endothelial Microparticle Levels Are Similar in Acute Ischemic Stroke and Stroke Mimics Due to Activation and Not Apoptosis/Necrosis

Academic Emergency Medicine ◽

10.1197/j.aem.2007.04.009 ◽

2007 ◽

Vol 14 (8) ◽

pp. 685-690 ◽

Cited By ~ 14

Author(s):

Justin B. Williams ◽

Edward C. Jauch ◽

Christopher J. Lindsell ◽

Begoña Campos

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Mimics

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Copeptin Levels in Patients With Acute Ischemic Stroke and Stroke Mimics

Stroke ◽

10.1161/strokeaha.115.009877 ◽

2015 ◽

Vol 46 (9) ◽

pp. 2426-2431 ◽

Cited By ~ 16

Author(s):

Matthias Wendt ◽

Martin Ebinger ◽

Alexander Kunz ◽

Michal Rozanski ◽

Carolin Waldschmidt ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Mimics

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Serum Level of Transferrin Unique Peptide Is Decreased in Patients With Acute Ischemic Stroke

Frontiers in Neurology ◽

10.3389/fneur.2021.619310 ◽

2021 ◽

Vol 12 ◽

Author(s):

Xizheng Hu ◽

Yinghui Li ◽

Peng Cheng ◽

Anhua Wu ◽

Guangyu Li

Keyword(s):

Ischemic Stroke ◽

Brain Tumor ◽

Acute Ischemic Stroke ◽

Glial Cell ◽

Cell Damage ◽

Interquartile Range ◽

Serum Biomarker ◽

Unique Peptide ◽

Stroke Mimics ◽

Stroke Group

Objectives: Free irons are transported into brain tissues by transferrin and play an important role in neuronal/glial cell damage. Lower serum levels of transferrin have been found in patients with ischemic stroke, compared with healthy subjects. In present study, we investigated whether transferrin unique peptide (TF-UP) could be employed as a serum biomarker for brain tissue damage in acute ischemic stroke.Methods: The venous blood samples of 94 ischemic stroke patients and 35 brain tumor-stroke mimics (BT-SM) patients were collected within the first 72 h (Median time 23.25, Interquartile range 60.75) of acute onset in the emergency room. Total TF-UP and total albumin unique peptide (Alb-UP) were identified with liquid chromatography/mass spectrometry (LC–MS/MS) and quantified by multiple reaction monitoring (MRM) method using labeled reference peptide (LRP) for further analysis.Results: Median ratio of total TF-UP/LRP was 0.85 (Interquartile range, 0.21) in the brain tumor-stroke mimics (BT-SM) group, and 0.45 (0.14) in the ischemic stroke group; median Alb-UP/LRP ratio was 0.66 (0.16) in the BT-SM group, and 0.55 (0.20) in the ischemic stroke group. The overall trend from low to high levels was statistically significant for TF-UP/LRP (P < 0.0001), but not for Alb-UP/LRP (P = 0.1667). According to the receiver operating characteristic (ROC) curve, the area under the curve (AUC) was 0.9565 and the optimal cutoff value of serum TF-UP was 0.6317, which yielded a sensitivity of 91.49% and a specificity of 88.57%. The odds ratio (95% confidence intervals) of serum TF-UP/LRP was 83.31 (23.43, 296.22, P < 0.0001).Conclusions: Serum TF-UP/LRP level is decreased in patients with acute ischemic stroke in comparison with brain tumor, and it may serve as a serum biomarker for the neuronal/glial cell damage in cerebral infarction.

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When migraine mimics stroke: A systematic review

Cephalalgia ◽

10.1177/0333102418767999 ◽

2018 ◽

Vol 38 (14) ◽

pp. 2068-2078 ◽

Cited By ~ 17

Author(s):

Alberto Terrin ◽

Giulia Toldo ◽

Mario Ermani ◽

Federico Mainardi ◽

Ferdinando Maggioni

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Adverse Events ◽

Acute Ischemic Stroke ◽

Migraine With Aura ◽

Thrombolytic Treatment ◽

Systemic Thrombolysis ◽

Stroke Mimics ◽

The Third ◽

Stroke Mimic

Background Migraine with aura may mimic an acute ischemic stroke, so that an improper administration of thrombolytic treatment can expose migrainous patients to severe adverse effects. Methods This systematic review quantifies the relevance of migraine with aura among stroke mimics, checking for thrombolysis’ safety in these patients. We reviewed the literature after 1995, distinguishing from studies dealing with stroke mimics treated with systemic thrombolysis and those who were not treated with systemic thrombolysis. Results Migraine with aura is responsible for 1.79% (CI 95% 0.82–3.79%) of all the emergency Stroke Unit evaluations and it represents 12.24% (CI 95% 6.34–22.31%) of stroke mimics in the group not treated with systemic thrombolysis. 6.65% (CI 95% 4.32–9.78%) of systemic thrombolysis administrations are performed in patients without an acute ischemic stroke. Migraine with aura is responsible for 17.91% of these (CI 95% 13.29–23.71%). The reported rate of adverse events seems extremely low (0.01%). Conclusion Migraine with aura is the third most common stroke mimic, following seizures and psychiatric disorders; it is responsible for about 18% of all improper thrombolytic treatments. Despite the absence of strong supporting data, thrombolysis in migraine with aura seems to be a procedure with an extremely low risk of adverse events.

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