Clinical Mimics: An Emergency Medicine-Focused Review of Stroke Mimics

Stroke is a leading cause of death and disability and most commonly presents with focal neurologic deficit within a specific vascular distribution. Several other conditions may present in a similar manner.

This review provides emergency providers with an understanding of stroke mimics, use of thrombolytics in these mimics, and keys to differentiate true stroke from mimic.

Stroke has significant morbidity and mortality, and the American Heart Association emphasizes rapid recognition and aggressive treatment for patients with possible stroke-like symptoms, including thrombolytics. However, many conditions mimic the presentation of stroke, with up to a 31% rate of misdiagnosis, leading to potentially harmful treatment. Stroke mimics are conditions that present with stroke-like symptoms, including seizures, headaches, metabolic, infection, space-occupying lesion, neurodegenerative disorder, peripheral neuropathy, syncope, vascular disorder, and functional disorder. Factors of history and physical examination supporting stroke vs. mimic are discussed, though any sudden-onset, objective, focal neurologic deficit in a patient should be assumed acute stroke until proven otherwise. Head computed tomography noncontrast is the first-line imaging modality. Magnetic resonance imaging is the most sensitive and specific imaging modality. Neurology consultation is recommended in the majority of patients. If stroke is suspected after evaluation, shared decision-making for further management and consideration of thrombolytics is recommended.

Stroke mimics present a conundrum for emergency providers. A new focal neurologic deficit warrants rapid evaluation for stroke with neuroimaging and neurology consultation. Several mimics found on assessment may resolve with treatment.