Intravenous thrombolysis in stroke mimics: results from the SITS International Stroke Thrombolysis Register

Abstract

Background and purpose Patients with stroke mimics (SM), i.e. conditions with stroke‐like symptoms, may risk harm if treated with intravenous thrombolysis (IVT). Current guidelines state low risk of intracerebral hemorrhage based on studies comprising a total of <400 SM cases. We aimed to compare safety and outcomes following IVT between patients with acute ischaemic stroke and mimicking conditions. Methods We included IVT‐treated ischaemic stroke patients in the SITS International Stroke Thrombolysis Register 2003–2017, examined with magnetic resonance imaging 22–36 h after treatment. Outcomes were parenchymal hematoma (PH) after treatment, symptomatic intracerebral hemorrhage (SICH) per Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS‐MOST), Second European Co‐operative Stroke Study (ECASS II) and National Institutes of Neurological Disorders and Stroke Study (NINDS) criteria, death and modified Rankin Scale score (mRS) at 3 months. Results Of 10 436 patients, 429 mimics (4.1%) were identified. The most common types were functional (30.8%), migraine (17.5%) and seizure (14.2%). Patients with mimics had fewer cerebrovascular risk factors and lower median National Institutes of Health Stroke Scale score [7 (interquartile range, 5–10) vs. 8 (5–14), P < 0.001]. Among mimics versus stroke patients, PH was seen in 1.2% vs. 5.1% (P < 0.001), SICH NINDS in 0.5% vs. 3.9% (P < 0.001), SICH ECASS II in 0.2% vs. 2.1% (P = 0.007) and SICH SITS‐MOST in 0% vs. 0.5% (P = 0.28). Modified Rankin Scale score 0–1 at 3 months was present in 84.1% vs. 57.7% (P < 0.001) and death within 3 months in 2.6% vs. 5.4% (P = 0.028) of mimics and stroke patients, respectively. Conclusions This large observational study indicated that PH and SICH following IVT in patients with SM are uncommon.

Stroke mimics: Clinical characteristics and outcome

“…3 In some patients with SM may erroneously receive intravenous thrombolysis therapy. 4,5 Stroke mimics are common in patients with suspected stroke. [3][4][5][6][7] Conditions that mimic stroke include metabolic disorders such as hypoglycemia, hyperglycemia, hypernatremia, hyponatremia, uremia, metabolic encephalopathy, and hyperthyroidism.…”

“…4,5 Stroke mimics are common in patients with suspected stroke. [3][4][5][6][7] Conditions that mimic stroke include metabolic disorders such as hypoglycemia, hyperglycemia, hypernatremia, hyponatremia, uremia, metabolic encephalopathy, and hyperthyroidism. 4,6,7,8 Moreover, migraine, seizure, psychological disorders, demyelinating diseases, and brain tumors may also mimic stroke.…”

“…[3][4][5][6][7] Conditions that mimic stroke include metabolic disorders such as hypoglycemia, hyperglycemia, hypernatremia, hyponatremia, uremia, metabolic encephalopathy, and hyperthyroidism. 4,6,7,8 Moreover, migraine, seizure, psychological disorders, demyelinating diseases, and brain tumors may also mimic stroke. 4,[6][7][8] The characteristics and statistics about SMs among suspected cases of stroke in Saudi Arabia have not been reported.…”

“…4,6,7,8 Moreover, migraine, seizure, psychological disorders, demyelinating diseases, and brain tumors may also mimic stroke. 4,[6][7][8] The characteristics and statistics about SMs among suspected cases of stroke in Saudi Arabia have not been reported. Yahia et al reported that 15.9% of patients with suspected stroke were SMs, psychiatric etiology was the commonest.…”

Neurologists should not blame emergency physicians for stroke mimics, but train them to identify chameleons

“…They are not likely to undergo mechanical thrombectomy because they have no large-vessel occlusion. They may receive an inappropriate treatment with rt-PA, but in this case, they have a very small risk of complication 5,6 . Finally, the only problem with mimics is an inappropriate use of available facilities 7 .…”