Because our stroke medical world can't objectively determine if you have a stroke, YOU WILL NEED TO HAVE CLASSIC SYMPTOMS; slurred speech, drooping arm, slumping face.
Stroke mimics: incidence, aetiology, clinical features and treatment
Abstract
Mimics account for almost half of hospital admissions for suspected stroke. Stroke mimics may present as a functional (conversion) disorder or may be part of the symptomatology of a neurological or medical disorder. While many underlying conditions can be recognized rapidly by careful assessment, a significant proportion of patients unfortunately still receive thrombolysis and admission to a high-intensity stroke unit with inherent risks and unnecessary costs. Accurate diagnosis is important as recurrent presentations may be common in many disorders. A non-contrast CT is not sufficient to make a diagnosis of acute stroke as the test may be normal very early following an acute stroke. Multi-modal CT or magnetic resonance imaging (MRI) may be helpful to confirm an acute ischaemic stroke and are necessary if stroke mimics are suspected. Treatment in neurological and medical mimics results in prompt resolution of the symptoms. Treatment of functional disorders can be challenging and is often incomplete and requires early psychiatric intervention.
The significance of the clinical problem
Stroke is one of the most common diseases affecting one in four people during their lifetime [1]. Most strokes are due to reduction or interruption of blood flow to the brain (ischaemic stroke). A small minority may result from thrombosis in medium or large cerebral veins. Approximately, 20–30% of strokes are haemorrhages and results from damage to small or medium-size vessels [1]. Stroke is a medical emergency and presents with focal neurological deficits. Immediate evaluation, confirmation of diagnosis and treatment to re-establish blood flow leads to improvement in symptoms and prevention of brain damage [2]. The diagnosis of acute ischaemic stroke is however not always straightforward. Similar symptoms may develop in a number of medical conditions commonly referred to as “stroke mimics” (see Table 1). It is essential to entertain stroke mimics in the differential diagnosis when treating an acute suspected stroke to avoid the inappropriate use of expensive and potentially harmful medications. This becomes particularly important with telestroke and in hospitals with limited acute stroke experience [3].
Table 1. Conditions that may be confused as acute stroke (stroke mimics).
The frequency of stroke mimics is variable and depends where the diagnosis is made and can for 20–50% of cases of acute suspected stroke depending if the patients are evaluated by the emergency personal or stroke physicians [3–5]. Stroke mimics can broadly be classified into two categories. Medical mimics are more common and comprise 50–80% of cases in most large series [4,6]. Functional mimics or conversion disorders are less frequent [7–10]. Although they have characteristic clinical features can sometimes be very difficult to differentiate from an ischaemic stroke (see Table 2). The separation of “new focal neurological symptoms” in the presence of an old stroke, also known as recrudescence, can be particularly challenging. This frequently develops in the settings of an acute infection or metabolic dysfunction and can occur weeks to years following a stroke [11]. Diagnosis may sometimes require magnetic resonance imaging (MRI) to determine if a new stroke is responsible for the focal symptoms. This is important when thrombolysis is being contemplated.
Table 2. Clinical characteristics differentiating stroke from mimic.
Stroke mimics have less clearly defined neurological symptoms that typically do not adhere to well-defined stroke syndromes [12]. The suddenness at onset is not always evident, fluctuations in severity are common and systemic signs including drowsiness, confusion, agitation and fever may be present [6]. Common presenting symptoms include vertigo and dizziness, altered level of consciousness, paraesthesia and numbness, monoplegia, speech dysfunction, limb ataxia, headache and visual disturbances (see Table 2). There is often a previous history of seizures, migraine, depression or other psychiatric disorders or dementia [4]. Mimics can be particularly difficult to differentiate from acute stroke when symptoms are brief and resolve before the patient is examined, especially when advanced brain imaging including MRI is normal. Prompt identification that symptoms are secondary to a stroke mimic and appropriate treatment of the underlying condition will lead to avoidance of potential misdiagnosis and the unnecessary long-term use of antithrombotic and other stroke prevention medication.
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