Stroke mimics in stroke code activations: frequency, diagnoses, treatment, and discharge destination

Objectives: To determine the frequency, of stroke mimics in stroke code activations, to analyze diagnoses, use of thrombolytic therapy and the discharge destinations of these patients; and to estimate the impact on these variables when patients over the age of 80 years are included. Methods: Prospective study of consecutive patients attended after stroke code activation; the study period was 50 months and the diagnostic image used was cranial computed tomography (CT). We compared the first period (20082010), in which we applied the SITS-MOST (Safe Implementation of Thrombolysis in Stroke Monitoring Study) criteria, to a second period (2010-2012), in which the time window for treatment was enlarged and there was no upper age limit for applying the criteria. Patients were grouped in 2 categories: stroke (transient or established, including cerebral infarction, transient ischemic attacks, and intracerebral hemorrhage) and pseudo-stroke (conditions mimicking stroke). Results: Stroke code was activated 1450 times; 288 cases were diagnosed as stroke mimics (19.9%; 95% CI, 17.7%21.9%). This group was younger and included more women. In the second period, in which more patients over 80 years of age were attended (6.0% in the first period vs. 22.6% in the second, P<.001), the percentage of cases diagnosed as stroke mimics decreased (23.8% in the first period, 16.2% in the second; P<.001). Mimics were less frequent in patients over the age of 80 years (14.5% vs. 20.4% in younger patients, P=.004). The most frequent diagnoses in patients with conditions mimicking stroke were epileptic seizures (15.6%; 95% CI, 18.2%-28.3%), syncope (16.8%; 95% CI, 12.1%-21.5%), and encephalopathy due to systemic disease (16.4%; 95% CI, 11.7%-21.1%). Thrombolytic therapy was used in 3 patients with mimics (1%; 95% CI, 0.2%-3.0%) without hemorrhagic complications, which occurred in 1.2% of the 257 patients under this therapy. Forty-six percent of the patients with mimics were hospitalized (95% CI, 36.1%-48.1%); 47.4% were evaluated by a neurologist. Conclusions: Stroke mimics are common and diagnosis is essentially clinical; evaluation by a neurologist is advisable. The frequency of stroke mimics was lower when patients over the age of 80 years were considered.