Original Article
Predictors of Acute Stroke Mimics in 8187 Patients Referred to a Stroke Service

https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.04.018Get rights and content

Background

Some patients seen by a stroke team do not have cerebrovascular disease but a condition that mimics stroke. The purpose of this study was to determine the rate and predictors of stroke mimics in a large sample.

Methods

This is an analysis of data from consecutive patients seen by the National Institutes of Health Stroke Program over 10 years. Data were collected prospectively as a quality improvement initiative. Patients with a cerebrovascular event or a stroke mimic were compared with the Student t or Pearson chi-square test as appropriate, and logistic regression was done to identify independent predictors.

Results

The analysis included 8187 patients: 30% had a stroke mimic. Patients with a stroke mimic were younger, and the proportion of patients with a stroke mimic was higher among women, patients without any risk factors, those seen as a code stroke or who arrived to the emergency department via personal vehicle, and those who had the onset of symptoms while inpatients. The proportion of patients with a stroke mimic was marginally higher among African-Americans than Caucasians. Factors associated with the greatest odds of having a stroke mimic in the logistic regression were lack of a history of hypertension, atrial fibrillation or hyperlipidemia.

Conclusions

One third of the patients seen by a stroke team over 10 years had a stroke mimic. Factors associated with a stroke mimic may be ascertained by an emergency physician before calling the stroke team.

Introduction

Stroke teams are often asked to see patients who have an abrupt onset of a neurological deficit—and, thus, possibly an ischemic or hemorrhagic stroke—but in whom the final diagnosis is not a cerebrovascular event.1, 2 Patients without a cerebrovascular etiology for their symptoms are considered to have a stroke mimic, and several small studies report that as many as one third of patients evaluated acutely by a stroke team, and up to 15% of patients treated with intravenous tissue plasminogen activator (t-PA), have such stroke mimics; potential etiologies include subdural hematoma, migraine, seizures, tumors, infections, multiple sclerosis, delirium, peripheral nerve injuries, and conversion disorders.3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 Several studies have evaluated the stroke mimic rate in different settings and have identified clinical and imaging features associated with a final diagnosis of stroke mimic, including clinical symptoms, vital signs, neurological signs, stroke severity, and even neurological impairment at discharge.3, 7, 10, 11, 12, 13, 14 Most of these factors, however, cannot be easily ascertained by the referring physician, often the emergency department (ED) doctor, before calling the stroke team. The purpose of this study was to answer 2 questions: What proportion of patients who are seen by an acute stroke team have a stroke mimic? What variables, if any, that are known by a referring physician before calling the stroke team (demographics, acuity, and medical history) can predict whether a patient has a stroke mimic? The answers to these questions may serve as a benchmark when assessing stroke team consult and response rates and may help determine the best allocation of a stroke team’s human resources.

Section snippets

Patients

This is an analysis of data from consecutive patients referred for evaluation of suspected stroke to the National Institutes of Health (NIH) Stroke Program at 2 hospitals in the Washington, DC, metropolitan area—Suburban Hospital (SH) and Medstar Washington Hospital Center (WHC)—between January 1, 2001, and December 31, 2010. The National Institute of Neurological Disorders and Stroke (NINDS) Intramural Stroke Branch established an NIH Stroke Program at these hospitals to conduct acute stroke

Results

Over a 10-year period, the NIH Stroke Team evaluated 8194 patients in person: 5066 (62%) had definite, probable, or possible AICS, 667 (8%) had an intracranial hemorrhage, and 2454 (30%) had a noncerebrovascular etiology for the symptoms—a stroke mimic. In 7 patients, the diagnosis was not recorded in the database. The analyses in this study are limited to the 8187 patients in whom the diagnosis (AICS, hemorrhagic stroke, or stroke mimic) was known. The NIH Stroke Team saw 4587 patients at SH

Discussion

In one third of the patients with suspected stroke seen acutely by a stroke team at 2 hospitals serving a multiracial and socioeconomically diverse population over 10 years, the presenting symptoms were because of conditions other than a cerebrovascular event (ie, they had a stroke mimic). Several patient characteristics that the referring physician can ascertain before calling the stroke team were associated with increased odds of having a stroke mimic, including demographic information,

Acknowledgment

We would like to acknowledge the assistance of the NIH Stroke Teams at SH and Washington Hospital Center over the past 10 years in the performance of this study.

References (16)

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Cited by (0)

The Division of Intramural Research of the National Institute of Neurological Disorders and Stroke of the National Institutes of Health supported this research.

Conflict of interest: The authors do not have any relevant conflict of interest to report.

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