Ischemic stroke mimics: A comprehensive review

For rtPA treatment to be effective it should be initiated within the first 4.5 hours following the onset of a stroke. Such a short therapeutic window demands a rapid diagnosis and decision making on the part of the physician. There are patients with stroke-like symptoms and an initial diagnosis of a stroke, but who are finally diagnosed as suffering from another condition. According to the subject literature, stroke mimics are diagnosed in about 1.4 – 3.5% of patients initially diagnosed as having had an ischemic stroke. Psychogenic strokes (conversion disorders) may be found in as many as 8.2% of stroke patients. Proper diagnosis is especially important in patients eligible for thrombolytic treatment when there is usually not enough time to establish the diagnosis of a stroke mimic, especially one of psychogenic origin. A patient with an initial diagnosis of an ischemic stroke who was treated with intravenous alteplase infusion. The previous two ischemic strokes treated in the same manner had been diagnosed one and two years earlier. In all hospitalizations no rtPA treatment complications had been observed. In our patient a proper neuropsychological examination was performed and a conversion disorder diagnosed. We would like to underline the importance of cooperation between the neuropsychologist and neurology physician within clinical practice.

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TCT-68 Safety and efficacy of stent retriever for the management of acute ischemic stroke. Comprehensive review and meta-analysis

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2015.08.845 ◽

2015 ◽

Vol 66 (15) ◽

pp. B30-B31

Author(s):

Konstantinos Marmagkiolis ◽

Abdul Hakeem ◽

Mehmet Cilingiroglu ◽

Cezar Iliescu ◽

Despina Tsitlakidou ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Meta Analysis ◽

Stent Retriever ◽

Safety And Efficacy ◽

Comprehensive Review

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Circulating Metabolites Differentiate Acute Ischemic Stroke from Stroke Mimics

Annals of Neurology ◽

10.1002/ana.25859 ◽

2020 ◽

Vol 88 (4) ◽

pp. 736-746

Author(s):

Steffen Tiedt ◽

Stefan Brandmaier ◽

Hanna Kollmeier ◽

Marco Duering ◽

Anna Artati ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Mimics

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EMERGENT MRI FOR DIFFERENTIATING ACUTE ISCHEMIC STROKE VERSUS STROKE MIMICS DURING A STROKE ALERT

10.26226/morressier.58e389aed462b802923857b2 ◽

2017 ◽

Author(s):

Evgeny Sidorov

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Mimics

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Abstract 2223: Diagnoses and Outcomes of t-PA Treated Patients with No Imaging Evidence of Acute Ischemic Stroke

Stroke ◽

10.1161/str.43.suppl_1.a2223 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Ilana Spokoyny ◽

Rema Raman ◽

Karin Ernstrom ◽

Brett C Meyer ◽

Thomas M Hemmen

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Clinical Diagnosis ◽

Surrogate Marker ◽

Stroke Patients ◽

Correct Treatment ◽

Stroke Mimics ◽

Stroke Imaging ◽

Significant Difference

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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Abstract 19: Machine Learning Approach Identifies a Pattern of Gene Expression in Peripheral Blood Which Can Accurately Detect Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.19 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Grant C O’Connell ◽

Ashley B Petrone ◽

Madison B Treadway ◽

Connie S Tennant ◽

Noelle Lucke-Wold ◽

...

Keyword(s):

Gene Expression ◽

Machine Learning ◽

Ischemic Stroke ◽

Whole Blood ◽

Validation Cohort ◽

Gene Expression Pattern ◽

Discovery Cohort ◽

Stroke Mimics ◽

Independent Validation ◽

Diagnostic Potential

Objective: The identification of stroke-associated biomarkers represents a means by which prehospital triage could be expedited to increase the probability of successful intervention. Thus, the objective of this work was to use high-throughput transcriptomics in combination with basic machine learning techniques to identify a pattern of gene expression in peripheral whole blood which could be used to identify acute ischemic stroke (AIS) in the acute care setting. Methods: A two-stage study design was used which included a discovery cohort and an independent validation cohort. In the discovery cohort, peripheral whole blood samples were obtained from 39 AIS patients upon emergency department admission, and from 24 neurologically asymptomatic controls. Microarray was used to measure the expression of over 22,000 genes and a pattern recognition technique known as genetic algorithm k-nearest neighbors (GA/kNN) identified a pattern of gene expression that optimally discriminated between AIS and controls. In an independent validation cohort, the gene expression pattern was tested for its ability to discriminate between 39 AIS patients and each of two different control groups, one consisting of 30 neurologically asymptomatic controls, and the other consisting of 15 stroke mimics, with gene expression levels being assessed by qRT-PCR. Results: In the discovery cohort, GA/kNN identified ten transcripts (ANTXR2, STK3, PDK4, CD163, MAL, GRAP, ID3, CTSZ, KIF1B, and PLXDC2) whose coordinate pattern of expression correctly identified 98.4% of subjects (97.4% sensitive, 100% specific). In the validation cohort, the same 10 transcripts correctly identified 95.6% of subjects when comparing AIS patients to asymptomatic controls (92.3% sensitive, 100% specific), and 96.3% of subjects when comparing AIS patients to stroke mimics (97.4% specific, 93.3% sensitive). Conclusion: These results demonstrate that a highly accurate RNA-based companion diagnostic for AIS is plausible using a relatively small number of markers. The pattern of gene expression identified in this study shows strong diagnostic potential, and warrants further evaluation to determine true clinical efficacy.

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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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Endovascular Therapy for Acute Ischemic Stroke: A Comprehensive Review of Current Status

Cardiovascular Revascularization Medicine ◽

10.1016/j.carrev.2018.07.010 ◽

2019 ◽

Vol 20 (5) ◽

pp. 424-431 ◽

Cited By ~ 2

Author(s):

İsmail D. Kilic ◽

Abdul Hakeem ◽

Konstantinos Marmagkiolis ◽

Andre Paixao ◽

Iris Grunwald ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Current Status ◽

Comprehensive Review

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Telestroke consultation can accurately diagnose ischemic stroke mimics

Journal of Telemedicine and Telecare ◽

10.1177/1357633x21989558 ◽

2021 ◽

pp. 1357633X2198955

Author(s):

Jason T Poon ◽

Aleksander Tkach ◽

Adam H de Havenon ◽

Knut Hoversten ◽

Jaleen Johnson ◽

...

Keyword(s):

Ischemic Stroke ◽

Predictive Value ◽

Clinical Information ◽

Excellent Correlation ◽

Stroke Mimics ◽

Intravenous Tissue Plasminogen Activator ◽

The Us ◽

Tissue Plasminogen ◽

Stroke Mimic ◽

Ischemic Attack

Introduction Telestroke (TS) networks are standard in many areas of the US. Despite TS systems having approximately 33% mimic rates, it is unknown if TS can accurately diagnose patients with acute ischemic stroke (AIS) versus stroke mimics. Methods We performed a retrospective review of consecutive TS consults to 27 TS sites in six states during 2018. Clinical information and diagnosis were extracted from discharge records and compared to those from the TS consult. Discharge diagnoses were verified and coded into 12 categories. Cases without a clear discharge diagnosis and intracerebral haemorrhage were excluded. We report agreement and a Cohen’s kappa between TS and discharge diagnoses for the category of AIS/transient ischemic attack (TIA) versus stroke mimic. Results We included 404 cases in the analysis (mean age 66 years; 54% women). Of these, 225 had a TS diagnosis of AIS/TIA; 102 (45%) received intravenous tissue plasminogen activator. Our study demonstrated a high diagnostic agreement for AIS/TIA (88%) with a kappa of 0.75 for stroke and mimics. Of the 179 patients diagnosed with a stroke mimic on TS, 27 (15%) were diagnosed with AIS/TA by discharge. TS mimic diagnosis had a positive predictive value (PPV) of 85% and a negative predictive value (NPV) of 90%; TS diagnosis of stroke/TIA had PPV 90%, NPV 85%. Discussion We found excellent correlation between TS and discharge diagnoses for patients with both stroke and stroke mimics. This suggests that TS systems can accurately assess a wider variety of patients with acute neurologic syndromes other than AIS.

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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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