Safety and Outcomes of Intravenous Thrombolysis in Stroke Mimics

Abstract

Background and Purpose-Efforts to increase the availability and shorten the time delivery of intravenous thrombolysis in patients with acute ischemic stroke carry the potential for tissue plasminogen activator administration in patients with diseases other than stroke, that is, stroke mimics (SMs). We aimed to determine safety and to describe outcomes of intravenous thrombolysis in SM. Methods-We retrospectively analyzed stroke registry data of consecutive acute ischemic stroke admissions treated with intravenous thrombolysis over a 6-year-period. The admission National Institutes of Health Stroke Scale score, vascular risk factors, ischemic lesions on brain MRI (routinely performed as part of diagnostic work-up), and discharge modified Rankin Scale scores were documented. Initial stroke diagnosis in the emergency department was compared with final discharge diagnosis. SM diagnosis was based on the absence of ischemic lesions on diffusion-weighted imaging sequences in addition to an alternate discharge diagnosis. Symptomatic intracranial hemorrhage was defined as brain imaging evidence of intracranial hemorrhage with clinical worsening by National Institutes of Health Stroke Scale score increase of Ն4 points. Results-Intravenous thrombolysis was administered in 539 patients with acute ischemic stroke (55% men; mean age, 66Ϯ15 years). Misdiagnosis of acute ischemic stroke was documented in 56 cases (10.4%; 95% CI, 7.9% to 13.3%). Conversion disorder (26.8%), complicated migraine (19.6%), and seizures (19.6%) were the 3 most common final diagnoses in SM. SMs were younger (mean age, 56Ϯ13 years) and had milder baseline stroke severity (median National Institutes of Health Stroke Scale, 6; interquartile range, 4) compared with patients with confirmed acute ischemic stroke (mean age, 67Ϯ14 years; median National Institutes of Health Stroke Scale, 8; interquartile range, 10; PϽ0.001). There was no case of symptomatic intracranial hemorrhage in SMs (0%; 95% CI, 0% to 5.5%); 96% of SMs were functionally independent at hospital discharge (modified Rankin Scale, 0 to 1). Conclusions-Our single-center data indicate favorable safety and outcomes of intravenous thrombolysis administered to SM. (Stroke. 2011;42:1771-1774.)

Assessing the Validity of the Cincinnati Prehospital Stroke Scale and the Medic Prehospital Assessment for Code Stroke in an Urban Emergency Medical Services Agency

“…Whereas the Med PACS had significantly better specificity than the CPSS, more recent stroke literature has suggested that the risk of administering t-PA to a patient with a stroke mimic is minimal, while not initiating t-PA therapy in stroke patients can have significant consequences. [24][25][26] Results from our study indicated that in an urban system where all local hospital emergency departments can deliver t-PA, a prehospital stroke screen such as the CPSS may be more useful. A screen with higher sensitivity allows for the prehospital system to alert/activate resources while lowering the probability of missing stroke patients.…”

Clinical features of stroke mimics in the emergency department

“…Several studies have reported on the predictors of stroke mimics (Table 4). 10, 14, 15, 16, 17 Most reported that stroke mimics were characterized by low vascular risk factors in young individuals and low NIHSS scores.…”

Imitadores del ictus: un reto para el médico de urgencias

“…Estas patologías que se presentan simulando un ictus pero que tras estudio se demuestra su diferente etiología son conocidas como imitadoras del ictus o pseudoictus (PI). En los servicios de urgencias hospitalarios (SUH) los PI representan de un 20 a un 30% de los pacientes ingresados con diagnóstico de ictus en un primer momento 1 , así como de un 1,4 a un 15% de los pacientes que reciben trombolisis con activador recombinante del plasminógeno tisular (rt-PA iv) tienen un diagnóstico final de PI [2][3][4][5][6][7][8][9] . La etiología es muy variada e incluye hematoma subdural, migraña, crisis comiciales, tumores, infecciones, esclerosis múltiple, trastornos somatomorfo 10 , delirio, etc [1][2][3][4][5][6][7][8][9][11][12][13][14][15][16][17] .…”

“…En los servicios de urgencias hospitalarios (SUH) los PI representan de un 20 a un 30% de los pacientes ingresados con diagnóstico de ictus en un primer momento 1 , así como de un 1,4 a un 15% de los pacientes que reciben trombolisis con activador recombinante del plasminógeno tisular (rt-PA iv) tienen un diagnóstico final de PI [2][3][4][5][6][7][8][9] . La etiología es muy variada e incluye hematoma subdural, migraña, crisis comiciales, tumores, infecciones, esclerosis múltiple, trastornos somatomorfo 10 , delirio, etc [1][2][3][4][5][6][7][8][9][11][12][13][14][15][16][17] . Estudios recientes han identificado las características clínicas y radiológicas asociadas a un diagnóstico final de PI incluyendo signos vitales, síntomas clínicos, signos neurológicos, gravedad del ictus e incluso las secuelas neurológi-cas al alta 2,4,5,11,15,18 .…”