Abstract 14767: Thrombolysis of Stroke Mimics via Telestroke

Introduction: Telestroke allows stroke expertise for thrombolysis decision making remotely using high-quality bidirectional audiovisual technology. Hypothesis: Intravenous tissue plasminogen activator (IVtPA) is administered via telestroke network to a proportion of patients without a stroke diagnosis (i.e. stroke mimic) Methods: Our academic comprehensive stroke program telestroke program includes 26 spoke Emergency rooms (ERs) through which IVtPA is administered throughout central Ohio. From July 1, 2016 to Sept 30, 2017, nearly all patients who received IVtPA at the outside hospital telestroke ERs were transferred to our institution for post-IVtPA care. Data was collected on final diagnosis, demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle (DTN) time, and outcomes. Results: Among 270 acute ischemic stroke patients who received IVtPA via telestroke, we identified 64 (23.7%) with a stroke mimic diagnosis. Stroke mimics were younger (mean age 56.4 vs 68.2, p <0.0001), more likely female (60.9% vs 45.6%, p 0.03), and had higher DTN times (85.3 vs 69.9 minutes, p 0.0008). The increase in DTN was due to longer time to recommend by the telestroke neurologist for stroke mimic (65.0 vs 53.2 minutes, p 0.0034). The stroke mimic diagnosis included Migraine 26 (40.6%), Factitious disorder 12 (18.8%), Encephalopathy 7 (10.9%), and Unmasking 6 (9.4%). The stroke mimics did not differ from each other based upon initial NIHSS, DTN, or sex. Compared to the other stroke mimics, Migraine and Factitious disorder patients were younger (51.2 vs 63.9 years, p <0.0006), more likely to have a personal history of migraines (42.1% vs 0%, p < 0.0001), and more likely to have functional exam findings (42.1% vs 3.8%, p 0.0007). There were no hemorrhagic complications in the stroke mimic patients. Among all stroke mimics, 26 (40.6%) had a history of similar prior episodes and 10 (15.6%) would have future recurrence of another similar episode, with 2 patients receiving IVtPA again in the future (1 Migraine and 1 Factitious disorder). Conclusions: In a tertiary academic telestroke network, nearly one-quarter of patients receive IVtPA for a non-stroke diagnosis, with migraine and factitious disorder being the most commonly seen.

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Abstract WP72: Early Experience on Intravenous Tissue Plasminogen Activator Delivery in Mobile Stroke Unit Patients with Stroke Mimics

Stroke ◽

10.1161/str.48.suppl_1.wp72 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Lila E Sheikhi ◽

Stacey Winners ◽

Pravin George ◽

Andrew Russman ◽

Zeshaun Khawaja ◽

...

Keyword(s):

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Stroke Unit ◽

Early Experience ◽

Final Diagnosis ◽

Stroke Mimics ◽

Intravenous Tissue Plasminogen Activator ◽

Mobile Stroke Unit ◽

Tissue Plasminogen ◽

Iv Tpa

Background: A mobile stroke unit (MSU) allows for early delivery for intravenous tissue plasminogen activator (IV-tPA). A proportion of IV-tPA treated patients may turn out to be stroke mimics. We evaluated the rate and complications seen in stroke mimics treated with tPA from our early experience on MSU. Methods: Retrospective review of patients treated with IV-tPA on the MSU from 2014 to 2016. Charts were reviewed for confirmed strokes by imaging (MRI or CT) and hemorrhagic transformation. Stroke mimics were defined as those without imaging evidence of infarction and a final diagnosis which was not suspected to be stroke. Results: Among 62 patients treated with IV-tPA, 14 (28.6%) had a final diagnosis consistent with a stroke mimics. The majority of these occurred in the first year of the MSU program. Most common mimics included conversion disorder (n=5) and seizures (n=5). While the last known well to IV-tPA times were similar, the MSU door-to-needle time was significantly longer in stroke mimics (38 vs 31 minutes, p = 0.03). No intracerebral hemorrhages or other IV-tPA related complications were identified in the stroke mimics group. Conclusions: In our early experience with MSU, treatment of stroke mimics occurred without IV-tPA related complications. This does not appear to be due to rushed decision making.

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Systolic blood pressure as a predictor of transient ischemic attack/minor stroke in emergency department patients under age 80: a prospective cohort study

BMC Neurology ◽

10.1186/s12883-019-1466-4 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 1

Author(s):

Andrew M. Penn ◽

Nicole S. Croteau ◽

Kristine Votova ◽

Colin Sedgwick ◽

Robert F. Balshaw ◽

...

Keyword(s):

Blood Pressure ◽

Emergency Department ◽

Transient Ischemic Attack ◽

Final Diagnosis ◽

Conditional Inference ◽

Minor Stroke ◽

Logistic Regression Models ◽

Stroke Mimics ◽

Stroke Mimic ◽

Ischemic Attack

Abstract Background Elevated blood pressure (BP) at emergency department (ED) presentation and advancing age have been associated with risk of ischemic stroke; however, the relationship between BP, age, and transient ischemic attack/minor stroke (TIA/MS) is not clear. Methods A multi-site, prospective, observational study of 1084 ED patients screened for suspected TIA/MS (symptom onset < 24 h, NIHSS< 4) between December 2013 and April 2016. Systolic and diastolic BP measurements (SBP, DBP) were taken at ED presentation. Final diagnosis was consensus adjudication by stroke neurologists; patients were diagnosed as either TIA/MS or stroke-mimic (non-cerebrovascular conditions). Conditional inference trees were used to define age cut-points for predicting binary diagnosis (TIA/MS or stroke-mimic). Logistic regression models were used to estimate the effect of BP, age, sex, and the age-BP interaction on predicting TIA/MS diagnosis. Results Over a 28-month period, 768 (71%) patients were diagnosed with TIA/MS: these patients were older (mean 71.6 years) and more likely to be male (58%) than stroke-mimics (61.4 years, 41%; each p < 0.001). TIA/MS patients had higher SBP than stroke-mimics (p < 0.001). DBP did not differ between the two groups (p = 0.191). SBP was predictive of TIA/MS diagnosis in younger patients, after accounting for age and sex; an increase of 10 mmHg systolic increased the odds of TIA/MS 18% (odds ratio [OR] 1.18, 95% CI 1.00–1.39) in patients < 60 years, and 23% (OR 1.23, 95% CI 11.12–1.35) in those 60–79 years, while not affecting the odds of TIA/MS in patients ≥80 years (OR 0.99, 95% CI 0.89–1.07). Conclusions Raised SBP in patients younger than 80 with suspected TIA/MS may be a useful clinical indicator upon initial presentation to help increase clinicians’ suspicion of TIA/MS. Trial registration ClinicalTrials.gov NCT03050099 (10-Feb-2017) and NCT03070067 (3-Mar-2017). Retrospectively registered.

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Migraine with Aura as a Stroke Mimic

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2019.316 ◽

2019 ◽

Vol 47 (2) ◽

pp. 242-244

Author(s):

Jeong-Jin Park ◽

Soo Jeong Kim ◽

Hahn Young Kim ◽

Hong Gee Roh ◽

Dong Wook Kim

Keyword(s):

Atrial Fibrillation ◽

Acute Stroke ◽

Migraine Attack ◽

Migraine With Aura ◽

Medical Records ◽

Final Diagnosis ◽

Stroke Management ◽

Stroke Mimics ◽

Management Protocol ◽

Stroke Mimic

ABSTRACT:Migraine with aura is one of the causes of stroke mimics. We retrospectively reviewed the 10-year medical records of patients who were treated with acute stroke management protocol. We analyzed the frequency and characteristics of patients with a final diagnosis of migraine with aura. Among the 1355 patients with stroke mimics, migraine with aura was the final diagnosis in 36 patients (2.7%). The most common auras included sensory and brainstem auras followed by motor, visual, and speech/language auras. One patient manifested transient atrial fibrillation during the migraine attack, which can be a link with acute stroke.

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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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Intravenous Thrombolysis for a Stroke Mimic Patient

Case Reports in Neurology ◽

10.1159/000519764 ◽

2021 ◽

pp. 704-709

Author(s):

Lilly Nguyen ◽

Joyce Hoonsuh Lee ◽

Latha Ganti ◽

Mark Rivera-Morales ◽

Larissa Dub

Keyword(s):

Cerebrovascular Disease ◽

Acute Stroke ◽

Plasminogen Activator ◽

Young Woman ◽

Intravenous Thrombolysis ◽

Herbal Supplements ◽

Stroke Mimics ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Stroke Mimic

The authors present the case of a young woman on phentermine and herbal supplements who presented as an acute stroke alert with right-sided facial droop and numbness. She was treated acutely with intravenous tissue plasminogen activator (tPA). However, the workup did not reveal any evidence of cerebrovascular disease or cerebral infarct. The authors discuss plausible stroke mimics and the safety of administering tPA to such patients.

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Abstract P275: Predicting Stroke Mimics in Telestroke Consultations

Stroke ◽

10.1161/str.52.suppl_1.p275 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Jennifer Siriwardane ◽

Holly Martin ◽

Brandon Edwards ◽

Michelle LaPradd ◽

Joanne Daggy ◽

...

Keyword(s):

Atrial Fibrillation ◽

Alcohol Abuse ◽

Stroke Care ◽

Bivariate Analysis ◽

P Value ◽

Metabolic Encephalopathy ◽

Stroke Mimics ◽

Chi Squared ◽

History Of ◽

Stroke Mimic

Background: Telestroke consultation is increasingly used to provide stroke care. Much like in-person stroke consults, stroke mimics are common. This study sought to identify patient and hospital characteristics more likely to be associated with a Telestroke diagnosis of stroke mimic. Methods: We analyzed 2 years of video consults by the VA National Telestroke Program (NTSP). Stroke mimic was defined as a Telestroke consult coded as a diagnosis of “other.” Text responses for “other” diagnoses were grouped into clinical categories. We used Chi-squared and t-tests analysis to compare characteristics of patients with a stroke mimic diagnosis and those without. Co-variates studied included age, gender, co-morbid conditions (history of dementia, cancer, or alcohol abuse), NIHSS, time of consult (night/weekend vs day), location of consult (emergency department vs inpatient), hospital rurality; hospital consult volume, and duration of institutional participation in NTSP at time of consult. Variables with a p-value < 0.25 in the bivariate analysis were included in the multivariate model. Results: There were 561 stroke mimics. The most common mimics were toxic metabolic encephalopathy (19%) and seizure (12%). Variables significantly associated with stroke mimic in bivariate analyses were age, gender, history of alcohol abuse, history of atrial fibrillation, history of dementia, NIHSS, nights/weekend consults, and hospital rurality. In multivariate analyses, female sex [OR=1.63, p=0.001], inpatient consultations [OR=1.55, p= 0.019], history of dementia [OR=1.85, p=0.0002], and alcohol abuse [OR=1.42, p=0.002] were associated with a stroke mimic. Consults during nights/weekends [OR=0.76, p=0.001], and patients with atrial fibrillation [OR=0.81, p=0.031], increasing age [OR=0.90, p=0.019], and increasing NIHSS [OR=0.97, p=0.0042] were less likely to be a mimic. Conclusion: Patient and consult characteristics influenced the likelihood of a stroke mimic diagnosis. Medical history may reflect conditions likely to cause neurologic symptoms, and patients hospitalized who have new symptoms represent a challenging subset to accurately distinguish stroke from mimics. Awareness of these factors may alert providers to diagnoses other than stroke.

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Abstract P32: Advanced Practice Provider-Based Acute Stroke Protocol Performs Well Compared to a Resident-Based Protocol

Stroke ◽

10.1161/str.52.suppl_1.p32 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Noah Grose ◽

Cassandra Forrest ◽

Sharon Heaton ◽

Vivien Lee

Keyword(s):

Acute Stroke ◽

Nurse Practitioners ◽

Final Diagnosis ◽

Reperfusion Therapy ◽

National Institutes Of Health ◽

Advanced Practice ◽

Intravenous Tissue Plasminogen Activator ◽

The Hours ◽

Comprehensive Stroke Center ◽

Stroke Center

Introduction: The administration of intravenous tissue plasminogen activator (IVtPA) for acute ischemic stroke (AIS) is typically done by neurology resident physicians at academic stroke centers. We sought to compare the performance of an advanced practice provider (APP)-based IVtPA protocol to a resident-based protocol. Methods: We performed a retrospective review of Emergency Room (ER) acute stroke codes from January 1, 2018 to January 1, 2019 that received AIS reperfusion therapy, including IVtPA or mechanical thrombectomy (MT). Inpatient AIS were excluded. During this timeframe, 5 acute stroke-trained nurse practitioners covered the daytime shifts for acute stroke codes on a rotating basis (during the hours of 7:00 am -4:00 pm, Monday through Friday). The neurology residents continued to cover all other stroke code shifts. We collected data on baseline demographics, initial National Institutes of Health Stroke Scale (NIHSS), door to needle (DTN) time, and door to groin puncture (DTG) time. Statistical analyses were performed using JMP software package (version 14). All tests were 2-sided, and a P value was considered significant at <0.05. Results: Among 322 AIS case who received acute reperfusion therapy, 133 (41.4%) received IVtPA, 200 (62.3%) received MT, and 11 (3.4%) received both. Among the 133 IVtPA patients, there was no difference in age (62.2 vs 59.9, p 0.56) or mean initial NIHSS (7.7 vs 8.2, p 0.75) when comparing the APP-based protocol to the resident-based protocol group, but patients seen by the APP were more likely to be male (78.3 vs 42.7%, p 0.0015). Compared to the resident-based protocol, the APP-based protocol had faster mean DTN times (38.9 vs 54.7 minutes, p 0.0374) and were more likely to have final diagnosis of stroke (95.7% vs 70%, p 0.0034). Among the 200 MT patients, the DTG time showed a trend for faster times for the APP-based protocol, although this was not significant (60.5 vs 76.5, p 0.0083). Conclusion: At our academic comprehensive stroke center, APP driven acute stroke code protocols perform as well as resident-based protocols in terms of time to reperfusion therapy.

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Variables That Best Differentiate In-Patient Acute Stroke from Stroke-Mimics with Acute Neurological Deficits

Stroke Research and Treatment ◽

10.1155/2016/4393127 ◽

2016 ◽

Vol 2016 ◽

pp. 1-6 ◽

Cited By ~ 3

Author(s):

P. Natteru ◽

M. R. Mohebbi ◽

P. George ◽

D. Wisco ◽

J. Gebel ◽

...

Keyword(s):

Emergency Department ◽

Indirect Costs ◽

Altered Mental Status ◽

Neurological Deficits ◽

Prior History ◽

Stroke Mimics ◽

Emergency Department Setting ◽

History Of ◽

Stroke Mimic ◽

One Year

Introduction. Strokes and stroke-mimics have been extensively studied in the emergency department setting. Although in-hospital strokes are less studied in comparison to strokes in the emergency department, they are a source of significant direct and indirect costs. Differentiating in-hospital strokes from stroke-mimics is important. Thus, our study aimed to identify variables that can differentiate in-hospital strokes from stroke-mimics. Methods. We present here a retrospective analysis of 93 patients over a one-year period (2009 to 2010), who were evaluated for a concern of in-hospital strokes. Results. About two-thirds (57) of these patients were determined to have a stroke, and the remaining (36) were stroke-mimics. Patients with in-hospital strokes were more likely to be obese (p=0.03), have been admitted to the cardiology service (p=0.01), have atrial fibrillation (p=0.03), have a weak hand or hemiparesis (p=0.03), and have a prior history of stroke (p=0.05), whereas, when the consults were called for “altered mental status” but no other deficits (p<0.0001), it is likely a stroke-mimic. Conclusion. This study demonstrates that in-hospital strokes are a common occurrence, and knowing the variables can aid in their timely diagnosis and treatment.

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Thrombolytic refusal over telestroke

Neurology Clinical Practice ◽

10.1212/cpj.0000000000000975 ◽

2020 ◽

pp. 10.1212/CPJ.0000000000000975

Author(s):

Alicia Zha ◽

Adriana Rosero ◽

Rene Malazarte ◽

Shima Bozorgui ◽

Christy Ankrom ◽

...

Keyword(s):

Racial Differences ◽

American Heart ◽

Heart Association ◽

Final Diagnosis ◽

Prior History ◽

Black Patients ◽

Tissue Plasminogen ◽

History Of ◽

Baseline Characteristics ◽

Stroke Mimic

IntroductionTissue plasminogen activator (tPA) refusal is 4%–6% for acute ischemic stroke (AIS) in the emergency room. Telestroke (TS) has increased the use of tPA for AIS, but is accompanied by barriers in communication that can affect tPA consent. We characterized the incidence of tPA refusal in our TS network and its associated reasons.MethodsPatients with AIS who were offered tPA within 4.5 hours from symptom onset according to American Heart Association guidelines were identified within our Lone Star Stroke Consortium Telestroke Registry from September 2015 to December 2018. We compared baseline characteristics and clinical outcomes between patients who refused tPA and patients who accepted tPA.ResultsAmong the 1242 patients who qualified for tPA and were offered treatment, 8% refused tPA. Female and non-Hispanic black patients and patients with prior history of stroke were more likely to decline tPA. Patients who refused tPA presented with a lower NIHSS and was associated with a final diagnosis of stroke mimic (odds ratio [0.23]; 95% confidence interval [CI] 0.15–0.36). Good outcome (90 days modified Rankin Scale 0–2) was the same among patients who received tPA and those who refused (OR 0.80; 95% CI 0.42–1.54). The most common reasons for refusal were rapidly improving and mild/non-disabling symptoms and concern for potential side effects.ConclusiontPA refusal over TS is comparable to previously reported rates; there was no difference in outcomes among patients who received tPA compared to those who refused. Sex and racial differences associated with an increase tPA refusal warrant further investigation in efforts to achieve equity/parity in tPA decisions.

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Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes

Neurology ◽

10.1212/wnl.0000000000004149 ◽

2017 ◽

Vol 89 (4) ◽

pp. 343-348 ◽

Cited By ~ 18

Author(s):

Tina M. Burton ◽

Marie Luby ◽

Zurab Nadareishvili ◽

Richard T. Benson ◽

John K. Lynch ◽

...

Keyword(s):

Clinical Outcomes ◽

Hemorrhagic Transformation ◽

Discharge Disposition ◽

Stroke Mimics ◽

Stroke Diagnosis ◽

Tissue Plasminogen ◽

Hospital Patients ◽

Stroke Mimic

Objective:To determine to what degree stroke mimics skew clinical outcomes and the potential effects of incorrect stroke diagnosis.Methods:This retrospective analysis of data from 2005 to 2014 included IV tissue plasminogen activator (tPA)–treated adults with clinical suspicion for acute ischemic stroke who were transferred or admitted directly to our 2 hub hospitals. Primary outcome measures compared CT-based spoke hospitals' and MRI-based hub hospitals' mimic rates, hemorrhagic transformation, follow-up modified Rankin Scale (mRS), and discharge disposition. Secondary outcomes were compared over time.Results:Of the 725 thrombolysis-treated patients, 29% were at spoke hospitals and 71% at hubs. Spoke hospital patients differed from hubs by age (mean 62 ± 15 vs 72 ± 15 years, p < 0.0001), risk factors (atrial fibrillation, 17% vs 32%, p < 0.0001; alcohol consumption, 9% vs 4%, p = 0.007; smoking, 23% vs 13%, p = 0.001), and mimics (16% vs 0.6%, p < 0.0001). Inclusion of mimics resulted in better outcomes for spokes vs hubs by mRS ≤1 (40% vs 27%, p = 0.002), parenchymal hematoma type 2 (3% vs 7%, p = 0.037), and discharge home (47% vs 37%, p = 0.01). Excluding mimics, there were no significant differences. Comparing epochs, spoke stroke mimic rate doubled (9%–20%, p = 0.03); hub rate was unchanged (0%–1%, p = 0.175).Conclusions:Thrombolysis of stroke mimics is increasing at our CT-based spoke hospitals and not at our MRI-based hub hospitals. Caution should be used in interpreting clinical outcomes based on large stroke databases when stroke diagnosis at discharge is unclear. Inadvertent reporting of treated stroke mimics as strokes will artificially elevate overall favorable clinical outcomes with additional downstream costs to patients and the health care system.

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