Stroke Mimics and Acute Stroke Evaluation: Clinical Differentiation and Complications after Intravenous Tissue Plasminogen Activator

Abstract

Background: Intravenous tissue-plasminogen activator remains the only U.S. Food and Drug Administration-approved treatment for acute ischemic stroke. Timely administration of fibrinolysis is balanced with the need for accurate diagnosis. Stroke mimics represent a heterogeneous group of patients presenting with acute-onset focal neurological deficits. If these patients arrive within the extended time window for acute stroke treatment, these stroke mimics may erroneously receive fibrinolytics.

Objective: This review explores the literature and presents strategies for differentiating stroke mimics.

Discussion: Clinical outcome in stroke mimics receiving fibrinolytics is overwhelmingly better than their stroke counterparts. However, the risk of symptomatic intracranial hemorrhage remains a real but rare possibility. Certain presenting complaints and epidemiological risk factors may help differentiate strokes from stroke mimics; however, detection of stroke often depends on presence of posterior vs. anterior circulation strokes. Availability of imaging modalities also assists in diagnosing stroke mimics, with magnetic resonance imaging offering the most sensitivity and specificity.

Conclusion: Stroke mimics remain a heterogeneous entity that is difficult to identify. All studies in the literature report that stroke mimics treated with intravenous fibrinolysis have better clinical outcome than their stroke counterparts. Although symptomatic intracranial hemorrhage remains a real threat, literature searches have identified only two cases of symptomatic intracranial hemorrhage in stroke mimics treated with fibrinolytics.

Keywords: fibrinolysis; hemorrhage; hemorrhagic transformation; safety; stroke; stroke mimic; symptomatic intracranial hemorrhage; tPA; thrombolysis; tissue plasminogen activator.