Stroke Mimics

Ahamad Hassan
Consultant Neurologist & Stroke Physician
Leeds Teaching Hospitals
Acute stroke is a treatable medical emergency

All These Interventions

Are time critical !!
 Stroke mimic

Popular term to distinguish patients presenting

often acutely with stroke-like symptoms but turn out
to have an alternative diagnosis

Not a disease, but a syndrome

“Get in the way”

Positive diagnosis and specific management

important in this group
Sensitivity 79-97%

Specificity 13-88%
Harbison et al Stroke 2003
BE-FAST (Balance, Eyes, Face, Arm,
Speech, Time)

Reducing the Proportion of Strokes Missed

Using the FAST Mnemonic

Reduced the number of missed strokes to 5-10%

Aroor et al Stroke 2017
 Stroke Mimics: A systematic Review

PRE HOSPITAL MIXED THROMBOLYSIS

PAPERS 6 37 16

Mean % 29 25 9
mimics

Top Mimic Seizures Seizures Migraine

Diagnosis Migraine Migraine Functional
Tumour Decompensation

McClelland G et al, PROSPERO 2015

Rosier scale
Used in Emergency room

7 point scoring system

Sensitivity 83-97%

Specificity 18-93%

“Weed out mimics in A+E”

Nor et al , Lancet Neurol 2005

 Causes of Stroke Mimics (n=109)
Condition % <6hrs >6hrs
Seizure 21.1 29.0 10.6
Sepsis 12.8 9.7 17.0
Toxic/metabolic 11.0 9.7 12.8
SOL 9.2 4.8 14.9
Syncope 9.2 14.5 2.1
Delirium 6.4 4.8 8.5
Vestibular 6.4 4.8 8.5
Mononeuropathy 5.5 6.5 4.3
Functional 5.5 6.5 4.3
Dementia 3.7 3.2 4.3
Migraine 2.8 3.2 4.3

Hand et al Stroke 2006

 Causes of Stroke Mimics (n=109)
Condition % <6hrs >6hrs
Seizure 21.1 29.0 10.6
Sepsis 12.8 9.7 17.0
Toxic/metabolic 11.0 9.7 12.8
SOL 9.2 4.8 14.9
Syncope 9.2 14.5 2.1
Delirium 6.4 4.8 8.5
Vestibular 6.4 4.8 8.5
Mononeuropathy 5.5 6.5 4.3
Functional 5.5 6.5 4.3
Dementia 3.7 3.2 4.3
Migraine 2.8 3.2 4.3
 Causes of Stroke Mimics (n=109)
Condition % <6hrs >6hrs
Seizure 21.1 29.0 10.6
Sepsis 12.8 9.7 17.0
Toxic/metabolic 11.0 9.7 12.8
SOL 9.2 4.8 14.9
Syncope 9.2 14.5 2.1
Delirium 6.4 4.8 8.5
Vestibular 6.4 4.8 8.5
Mononeuropathy 5.5 6.5 4.3
Functional 5.5 6.5 4.3
Dementia 3.7 3.2 4.3
Migraine 2.8 3.2 4.3
Safety of TPA in Stroke Mimics
2 large series >500 patients Rx

Stroke Misdiagnosis rate =10-14%

No cases of SICH

90% functionally independent

Message if in doubt Rx !

Chernyshev et al 2010, Tsivgoulis 2011

Recognition tools
 Useful for rapid screening
Neurological History/Exam remains essential
 Fall back position in ‘grey cases’
 Some Tips
NIH stroke scale
Quantify stroke severity in a consistent way

Objectively scoring number/magnitude focal deficits

 Predicts lesion size and stroke outcome

 Predicts large vessel occlusion

 Useful in determining suitability for thrombolysis

 ? Role in stroke diagnosis

NIH stroke scale
11 item (42 point scale)
 Conscious level
 Eye movements
 Vision
 Motor power in limbs/face
 Co-ordination
 Sensation
 Language
 Articulation
 Inattention
Proportion brain attacks attributable to stroke or mimic
subdivided by NIHSS score

Hand et al Stroke 2006

Logistic regression model for predicting diagnosis of
brain attack

OR 95%CI

Known cognitive impairment 0.33 0.14-0.76

Exact onset determined 2.59 (1.30-5.15)

Definite focal symptoms 7.21 (2.48-20.93)

Abnormal vascular findings 2.54 (1.28-5.07)

NIHSS

1-4 1.92 (0.70-5.23)

5-10 3.14 (1.03-9.65)

>10 7.23 (2.18-24.05)

Signs localise to either left or right 2.03 (0.92-4.46)

OCSP classification possible 5.09 (2.42-10.70)

 Symptom Pattern

B
A

C
 SEPSIS AND SYNCOPE
 Radiology report “Established Lacune”

 Unmask old deficits- Toxic effects or

hypoperfusion

 Evidence of metabolic/systemic disturbance

 Confusion/Delirium may be mistaken for dysphasia

 Be wary of aspiration pneumonia in acute stroke

 Seizure Disorders
Todd, 1854
“ A paralytic state remains sometime after the epileptic
convulsion. This is more particularly the case when the
convulsion has only affected one side or limb:
That limb or limbs will remain paralytic for several hours or
even days after the cessation of the paroxysm, but will
ultimately recover”

Range of post seizure deficits extended to include,

hemianopia, blindness
aphasia, sensory loss, stupor confusion
 Todd’s Paresis
 Generalised Epilepsy 6%

 Focal Epilepsy 13%

 Post ictal paralysis variable 11s-36 hours

 Established brain injury (often old stroke)

Focal Epilepsies

 Ipsilateral motor phenomena 90%

clonic shaking (mild)
dystonic posturing
hand automatisms

 No Motor Activity 10%

Inhibitory seizure

Rolak 1992, Allmetzer 2004

Acute Symptomatic Seizure Following Stroke
5% with stroke present with 1st seizure

Predictors

Haemorrhagic transformation OR= 2.7 vs Ischaemic stroke

PICH OR= 7.2 vs Ischaemic stroke

Cortical features OR= 3.1 vs subcortical

Take home message

1st seizure with hemiparesis, needs urgent CT

If no bleed, no cortical features v.likely to be TODD’S palsy

Beghi et al 2011
Migraine with Aura
 Recurrent Disorder

 Symptoms have a slow migratory pattern

Coincide with spreading depression
(depolarisation wave spreads across cortex 3-5mm/s)

 Visual> Speech> Sensory

 Develop over 5-20minutes

 Lasts less than 60 minutes

 Headache usually present (can be absent), follows

aura.

 Other causes ruled out (Headache commonly accompanies stroke)

Hemiplegic Migraine

Can be sporadic/familial

Prevalence = 1/10000

FHM1 (CACNA1A) FHM2 (ATP1A2) FHM3 (SCN1A)

Weakness+ additional aura lasts longer up to 24 hours

Typical march

May have a basilar feel e.g. confusion, ataxia, coma

Occasionally seizures

Attacks sometimes v. prolonged

Triggered by head trauma, catheter angiogram

Interictal problems e.g. progressive ataxia

Migraine with unilateral motor weakness (MUMS)

Onset usually later in 30s (unlike FHM in teens, 20s)

Give way weakness frequently found

Spreading weakness

Weakness improves with treatment of headache/pain

Associated with more diffuse pain

Atypical aura?

Functional

Behavioural response to pain

No difference in anxiety/mood scores

 Functional Hemiparesis

History
Examination

Investigations

Look for Consistent Inconsistency!

Functional Hemiparesis
(Stone et al 2010, case control study, n=107)

Features suggestive in history

High proportion of women but similar in controls

Left hemiparesis not seen more commonly

Multiple symptoms especially pain and fatigue

Other functional problems e.g. IBS, fibromyalgia, CFS

Early hysterectomy (for menorrhagia)

Higher frequency of depression, anxiety disorders

Feel stress is not the cause (vs organic disease)

Less likely to be working

Multiple attacks over long period (+/-normal brain imaging)

 Stroke or Mimic?
85 year old man

Lives in nursing home, mild dementia

Found slumped by carers in chair, rousable

Twitching right side of mouth

Usually confused (? Slightly worse)

Slurred speech

Mild weakness right arm (NIHSS =5)

Temperature 37.8oC

BM=4.5mmol/l
ROSIER Score

=1
Stroke?
Rosier +
Motor weakness
Abrupt onset

Todd’s Paresis
Low Rosier score
Low NIHSS score
Cognitive impairment
Mild pyrexia
Seizure activity
No bleed on scan
 Stroke or Mimic?
44 year old man

6 hour history of vomiting and vertigo

Unsteady on feet, coarse nystagmus

photophobic

BP 150/90, BM 6.3

Paramedic FAST Test negative

Anything else you want to ask?

What would you do next?

ROSIER score =0
CT Brain Normal
Sent Home from A+E. Came back next day, drowsy with headache
Has My Dizzy Patient had a Stroke?

Acute Vestibular Syndrome

Syndrome of Dizziness developing acutely, accompanied by nausea, vomiting,

unsteady gait, nystagmus, intolerance to head motion, lasting 24 hours or
more (+/- other focal neurology)

Vestibular neuritis majority

Stroke estimated to account for 25%

Commonly missed in A+E depts

Patients come back in with space occupying cerebellar stroke or progressive

basilar syndromes

I would definitely discuss this patient with my stroke consultant/neurologist

especially if symptoms persisting in ED
HINTS (Kattah et al 2009)

Composite of 3 tests

Head impulse test (Vestibular occular reflex)

Direction changing horizontal nystagmus

Skew deviation

INFARCT

Any 1 of 3 sensitivity 100% Specificity 98%

Better than acute DWI-MRI !!

“Ulnar neuropathy” “Left sided Bell’s palsy”

All hand muscles affected But subtle ataxia

Brisk reflexes

Abrupt Onset + Good examination skills are also needed

Will a scan help me? (Non contrast CT)

•Widely available,

• IF ICH Yes!

•Often normal in ischaemic CVA

• Early infarct signs confirm clinical suspicion of stroke

• Rarely non stroke neurological mimics seen e.g. SOL

or sub dural haematoma (but often history is “fishy”)

• Rarely clarifies clinical picture, if stroke is uncertain

from outset (advanced imaging more useful)
 Stroke or Mimic: Radiology

Hyperdensity distal MCA Hyperdensity ICA

Hyperdensity MCA

Excellent inter observer reliability. Low sensitivity, very high specificity 95-100%
(If definitely present on the correct side confident that not stroke mimic)
Perfusion CT CT-A MR-DWI

Advanced imaging
66 year old lady found collapsed, GCS=6, temperature 37.5

? Encephalitis
Take Home Messages
Stroke recognition tools allow rapid detection of stroke
with very good sensitivity and specificity

Approx 20% strokes referred for hyperacute treatment

will be mimics

Watch out for stroke chameleons, sometimes hard to

spot

Key discriminators from history and examination can

improve diagnostic accuracy.

Advanced Neuroimaging can play a useful role

In difficult cases