Stroke Mimics: The Stroke That Wasn’t

Yes, stroke treatment must be done quickly. However, caution is needed – as some typical symptoms have other causes.

After cardiovascular diseases, stroke is the most common cause of death in Germany and worldwide. However, a distinction must be made between two types: ischemic stroke, in which the brain is no longer supplied with blood by an artery, and strokes caused by cerebral hemorrhage. This distinction is crucial because in an ischemic stroke, rapid dissolution of the blockage with thrombolysis may help, whereas a cerebral hemorrhage would only worsen.

A correct diagnosis is so important

For this reason alone, doctors examine patients suspected of having a stroke using imaging methods (computed tomography or magnetic resonance imaging). But there’s another reason: not everything that looks like a stroke actually is. Stroke mimics, also called stroke mimics, are neurological diseases whose symptoms are similar to those of a stroke. “One of the most common causes of stroke imitations are blood pressure crises, which can be accompanied by stroke-like symptoms such as hemiplegia,” says Professor Ulf Ziemann, Medical Director of Neurology at the University Hospital Tübingen. Hypo- and hyperglycemia, epileptic seizures (especially Todd’s paresis), migraine with aura, and disorders of the vestibular system also appear.

It is not so easy to determine how often stroke mimics occur. Ziemann estimates that about ten to 15 percent of patients who come to the clinic with a suspected stroke actually have another condition. A study from the USA even states 26 percent and shows that it depends a lot on who makes the initial diagnosis – emergency services or service doctors.

Catch on Stroke Mimics

Some imitations of a stroke can be recognized quite well: blood pressure crises by measuring blood pressure, hypo- and hyperglycemia by measuring blood sugar. “In the case of epileptic seizures and migraines, a good history can help clarify whether all the symptoms started at the same time or in rapid succession,” explains Ziemann. Other possible causes, such as brain tumors, can be detected by imaging.

In and of themselves, stroke mimicry is not necessarily problematic. Time itself causes complications, argue doctors from Switzerland around Dr. Lehel-Barna Lakatos in a review article: “There is an effort to optimize the timing between arrival, diagnosis and initiation of therapy (door-to-needle time).” This increases the risk of misjudgment.

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When is late lysis dangerous – and when is it not

This in turn means that more patients mimicking stroke are mistakenly treated with thrombolytic therapy. Lakatoš and colleagues write that, in addition to the psychological effects of unwarranted treatment, this leads to delays in the correct diagnosis, unnecessary examinations, and excess follow-up needs and drug costs. However, as Ziemann points out, the consequences of late lysis for real stroke patients are usually much worse than excess lysis for stroke mimics. Other doctors also advise not to spend too much time on diagnosis, especially since unnecessary thrombolytic therapy usually does not cause any disorders – unless it is inappropriate for other reasons.

Finally, if a stroke is suspected, it’s important to get the victim to a specialized facility as quickly as possible, Ziemann says. “We are in a good position in Germany because we have the most comprehensive range of stroke departments in the world.” In this way, an acute diagnosis can be made quickly and even mimics of a stroke can be recognized at an early stage.

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