Clinical characteristics and management of functional neurological disorders (FND) mimicking stroke in emergency settings: a functional stroke mimic cases.

Background: FNDs mimicking a stroke represent a growing challenge in the emergency department (ED). A comprehensive diagnostic approach involving clinical evaluation and neuroimaging is essential to differentiate stroke from mimics. The safety profile of thrombolysis justifies its use where FNDs cannot be ruled out. This approach highlights the need for more precise diagnostic tools and protocols to improve patient care and reduce unnecessary treatments. Distinguishing FNDs from actual cerebrovascular events is critical yet difficult, particularly under time constraints. Given the urgency and potential severity of strokes, intravenous thrombolysis is frequently administered even when FNDs cannot be definitively excluded. Methods: This retrospective study analyzed data of participants admitted to the Trieste University Hospital Stroke Unit between January 2018 and December 2022, focusing on those presenting with sudden-onset focal neurological deficits mimicking a stroke, with some presenting within the reperfusion treatment window (<4.5 h from symptoms onset). We obtained detailed clinical evaluations and neuroimaging, and administered thrombolytic therapy in selected cases. Results and discussion: We included 84 participants presenting with stroke mimics (average age of 45 yo) predominantly female (65.5%). Most common presentations: hemiparesis or hemisensory loss (75%), speech disorder (10.7%), vertigo/gait disorders (4.8%). History of psychiatric disorders was found in 32.1% of cases, and 48.8% had prior neurological disease or stroke risk factors. Advanced neuroimaging was performed in 43 cases yielding normal or non-specific results. Thrombolysis was safely administered in 31%. Patients mostly recovered within the first 24 h from admission (44.7%). We compared this FND's sample with 291 patients with mild ischemic stroke (NIHSS ≤7).

Poor prediction of stroke mimics using validated stroke mimic scales in a large academic telestroke network.

INTRODUCTION: Telestroke enables timely and remote evaluation of patients with acute stroke syndromes. However, stroke mimics represent more than 30% of this population. Given the resources required for the management of suspected acute ischemic stroke, several scales have been developed to help identify stroke mimics. Our objective was to externally validate four mimic scales (Khan Score (KS), TeleStroke Mimic Score (TS), simplified FABS (sFABS), and FABS) in a large, academic telestroke network. METHODS: This is a retrospective, Institutional Review Board-exempt study of all patients who presented with suspected acute stroke syndromes and underwent video evaluation between 2019 and 2020 at a large academic telestroke network. Detailed chart review was conducted to extract both the variables needed to apply the mimic scales, the final diagnosis confirmed by final imaging, and discharge diagnosis (cerebral ischemic vs stroke mimic). Overall score performance was assessed by calculating the area under curve (AUC). Youden cutpoint was established for each scale and used to calculate sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy. RESULTS: A total of 1043 patients were included in the final analysis. Final diagnosis of cerebral ischemia was made in 63.5% of all patients, and stroke mimic was diagnosed in 381 patients (36.5%). To predict stroke mimic, TS had the highest AUC (68.3), sensitivity (99.2%), and NPV (77.3%); KS had the highest accuracy (67.5%); FABS had the highest specificity (55.1%), and PPV (72.5%). CONCLUSIONS: While each scale offers unique strengths, none was able to identify stroke mimics effectively enough to confidently apply in clinical practice. There remains a need for significant clinical judgment to determine the likelihood of stroke mimic at presentation.

Prehospital stroke detection scales: A head-to-head comparison of 7 scales in patients with suspected stroke.

BACKGROUND: Several prehospital scales have been designed to aid paramedics in identifying stroke patients in the ambulance setting. However, external validation and comparison of these scales are largely lacking. AIMS: To compare all published prehospital stroke detection scales in a large cohort of unselected stroke code patients. METHODS: We conducted a systematic literature search to identify all stroke detection scales. Scales were reconstructed with prehospital acquired data from two observational cohort studies: the Leiden Prehospital Stroke Study (LPSS) and PREhospital triage of patients with suspected STrOke (PRESTO) study. These included stroke code patients from four ambulance regions in the Netherlands, including 15 hospitals and serving 4 million people. For each scale, we calculated the accuracy, sensitivity, and specificity for a diagnosis of stroke (ischemic, hemorrhagic, or transient ischemic attack (TIA)). Moreover, we assessed the proportion of stroke patients who received reperfusion treatment with intravenous thrombolysis or endovascular thrombectomy that would have been missed by each scale. RESULTS: We identified 14 scales, of which 7 (CPSS, FAST, LAPSS, MASS, MedPACS, OPSS, and sNIHSS-EMS) could be reconstructed. Of 3317 included stroke code patients, 2240 (67.5%) had a stroke (1528 ischemic, 242 hemorrhagic, 470 TIA) and 1077 (32.5%) a stroke mimic. Of ischemic stroke patients, 715 (46.8%) received reperfusion treatment. Accuracies ranged from 0.60 (LAPSS) to 0.66 (MedPACS, OPSS, and sNIHSS-EMS), sensitivities from 66% (LAPSS) to 84% (MedPACS and sNIHSS-EMS), and specificities from 28% (sNIHSS-EMS) to 49% (LAPSS). MedPACS, OPSS, and sNIHSS-EMS missed the fewest reperfusion-treated patients (10.3-11.2%), whereas LAPSS missed the most (25.5%). CONCLUSIONS: Prehospital stroke detection scales generally exhibited high sensitivity but low specificity. While LAPSS performed the poorest, MedPACS, sNIHSS-EMS, and OPSS demonstrated the highest accuracy and missed the fewest reperfusion-treated stroke patients. Use of the most accurate scale could reduce unnecessary stroke code activations for patients with a stroke mimic by almost a third, but at the cost of missing 16% of strokes and 10% of patients who received reperfusion treatment.

Distinguishing Cerebral Infarction With Neck Pain and Hemiparesis From Cervical Spinal Epidural Hematoma Without MRI: A Case Report.

In patients presenting neck pain and hemiparesis, differentiation between cerebral infarction and cervical spinal epidural hematoma is vital yet challenging, particularly when magnetic resonance imaging (MRI) is not feasible. A 59-year-old woman presented with a sudden onset of left-sided hemiparesis and neck pain. MRI was contraindicated because the patient underwent embolization in childhood. Head computed tomography (CT) revealed no evidence of hemorrhage or early ischemic signs. Cervical CT revealed no evidence of hematoma within the spinal canal. Myelography and CT myelography revealed no significant cervical spine abnormalities. The diagnosis was cerebral infarction. Cervical spine MRI is the gold standard examination for diagnosing cervical spinal epidural hematoma, but cervical spine CT, myelography, and CT myelography may be useful when MRI is contraindicated.

Hereditary Creutzfeldt-Jakob Disease: A Case Presentation of a Rare Stroke Mimic.

Acute ischemic cerebrovascular accident (CVA) is a time-sensitive emergent diagnosis, requiring rapid diagnosis and consideration of thrombolytic administration. However, a myriad of cerebrovascular mimics creates a diagnostic challenge. A rare CVA mimic is Creutzfeldt-Jakob disease (CJD), a rapidly progressive fatal dementia due to protein misfolding. Magnetic resonance imaging (MRI) and neurology consultation for electroencephalogram (EEG) and specialized cerebrospinal fluid (CSF) studies are diagnostic while the patient is alive. All forms are fatal within months, and diagnosis can be confirmed on postmortem brain testing. While incredibly uncommon, emergency clinicians should consider this diagnosis in the proper patient to advocate for specialized CSF testing and potential palliative care consultation.

Methotrexate-Induced Leukoencephalopathy as a Clinical and Radiological Mimicker of Acute Ischemic Stroke Leading to Thrombolysis.

Methotrexate (MTX) is used to treat acute lymphoblastic leukemia (ALL). It acts by inhibiting cell proliferation through its role as a folate antagonist. Despite its positive impact on patients' survival, high-dose MTX therapy carries risks, notably neurotoxic side effects such as subacute leukoencephalopathy that can mimic stroke symptoms. Recognizing and managing MTX-induced neurotoxicity promptly is crucial. We present a case involving an 18-year-old male diagnosed with B-cell ALL who presented with symptoms of MTX-induced leukoencephalopathy, initially resembling a stroke. The initial neurological examination and imaging results closely resembled those of a stroke, prompting the activation of a stroke code. Due to uncertainty regarding whether it was an acute ischemic stroke, the patient underwent thrombolysis. However, a thorough assessment of the medical history, treatment timeline, and imaging features, combined with the absence of large vessel occlusions on the magnetic resonance angiogram, led to the diagnosis of MTX-induced leukoencephalopathy. Our patient demonstrated complete clinical and radiological improvement within the following ten days. This underscores the significance of thorough history-taking, especially regarding drug history, to distinguish stroke mimics and contemplate MTX-induced leukoencephalopathy as a potential factor in ALL patients receiving MTX treatment. Recognizing these cases is essential to preventing unnecessary thrombolysis.

A Stroke Mimic With Postictal Todd's Paresis and a Simplified Guide to Management of Acute Hyponatremia.

Stroke mimics typically involve non-vascular disease processes, accounting for approximately half of hospital admissions for suspected stroke. These mimics may manifest as functional (conversion) disorders or indicate other neurological or medical conditions, including hypoglycemia, brain tumors, toxic poisoning, migraines, sepsis, seizures, and electrolyte imbalances, which can imitate stroke symptoms, making the diagnosis complex. In this report, we present a unique case of a man in his sixties who developed acute postoperative hyponatremia, an electrolyte abnormality frequently encountered but rarely presented with focal neurological deficits. This condition resulted in facial asymmetry and hemiparesis; however, the remarkable outcome was that these deficits were completely resolved once the hyponatremia was corrected.

Post-Stroke Recrudescence: A Case Report and Literature Review.

Post-stroke recrudescence (PSR) is a clinical entity characterized by the acute transient recurrence of previously recovered focal stroke deficits. Various names have been used to describe PSR, which further complicates its diagnosis. Increased awareness of this condition is crucial for preventing inappropriate management and unnecessary testing. Mechanisms proposed for PSR include altered drug response in diseased brain areas and immune activation due to a compromised blood-brain barrier (BBB). Patients with PSR have a distinct vascular risk profile and fewer cardiovascular complications than those with transient ischemic attacks (TIAs). Accurate differentiation of PSR from other conditions that mimic stroke is essential for its appropriate management. Misdiagnosis may lead to unnecessary procedures and prolonged hospitalization. This article presents the case of a 56-year-old female with multiple episodes of PSR that were initially misdiagnosed in the emergency department. The patient had a history of hypertension and ischemic stroke, and her episodes of PSR were often triggered by elevated blood pressure. Future studies should focus on developing validated prediction scores to guide recurrent stroke workup. Enhancing awareness and understanding of PSR can optimize resource allocation and improve patient outcomes.

A stroke mimic with left-hemispheric leptomeningeal vessel paucity and hypoperfusion.

In the neuroimaging workup of a suspected ischemic stroke, the involvement of more than one arterial territory without an anatomical substrate should raise the suspicion of a stroke mimic. We report the case of a 61-year-old male with a new-onset headache and transient phasic disturbances who presented a pattern of vascular abnormalities characterized by left-hemispheric leptomeningeal vessel paucity and hypoperfusion.

Herpes Simplex Virus Meningoencephalitis Masquerading as Acute Stroke With Broca's Aphasia: A Case Report.

This case report presents a rare and unique instance of a 70-year-old morbidly obese female with type 2 diabetes mellitus and bilateral lymphedema, who presented with fever and expressive aphasia, initially suspected to be a stroke. A negative CT scan prompted the performance of an MRI, which revealed suggestive imaging findings of herpes encephalitis. Following the MRI, the patient experienced seizures and required intubation in the intensive care unit. Subsequently, a lumbar puncture was performed, confirming the diagnosis of herpes simplex virus (HSV) meningoencephalitis. Prompt initiation of acyclovir therapy led to an improvement in aphasia, ultimately allowing for extubation and transfer to the general ward. The rarity of this case lies in the unusual manifestation of Broca's aphasia caused by HSV, which is not typically associated with this neurological deficit. This report highlights the importance of considering herpes encephalitis as a potential etiology in patients presenting with atypical neurological symptoms, even in the absence of typical radiological findings. Early diagnosis and appropriate management with acyclovir are crucial in improving outcomes in such cases.

Tumefactive demyelinating disorders as stroke mimics: Description of cases and systematic review of the literature.

BACKGROUND: tumefactive multiple sclerosis (TmMS) is a rare subtype of a demyelinating disease that develops over time. Cases of hyperacute presentations mimicking cerebrovascular disorders have been reported; however, detailed clinical and demographic data are lacking. METHODS: this study aimed to systematically review the literature on tumefactive demyelinating disorders presenting as strokes. After screening the PubMed, PubMed Central, and Web of Science databases, 39 articles describing 41 patients were identified, including 2 historical patients from our center. RESULTS: 23 (53.4%) patients were diagnosed with multiple sclerosis variants (vMS), 17 (39.5%) with inflammatory demyelinating variants (vInf), and 3 with tumors; however, only 43.5% of cases were verified histologically. In subgroup analysis, vMS differed from vInf in several aspects. Inflammatory cerebral spinal fluid parameters, including pleocytosis, proteinorachia was more commonly observed in vInf [11 (64.7%) vs. 1 (5.2%), P = 0.001 and 13/17 (76.4%) vs. 6/23 (31.5%), P = 0.02] than that in vMS. Neurological deterioration and fatal outcomes were more commonly observed in vInf [13/17 (76.4%) vs. 7/23 (30.4%), P = 0.003, and 11/17 (64.7%) vs. 0/23 (0%), P = 0.0001] than that in vMS. CONCLUSIONS: Clinicodemographic data might aid in recognizing different subtypes of TmMS and warrant consideration of unconventional therapies because outcomes may be poor in the vInf of TmMS.

Rational clinical approach to transient ischaemic attack, stroke and associated mimics: A retrospective cohort study.

OBJECTIVE: The present study was performed to identify the individual clinical features and risk factors most strongly associated with the diagnosis of transient neurological symptoms with a cerebrovascular cause (transient ischaemic attack (TIA) or stroke), as compared to common TIA mimics (including retinal ischaemia, migraine and seizure). METHODS: In a retrospective cohort study, consecutive patients presenting with transient neurological symptoms to TIA clinic in Royal Adelaide Hospital were included. Clinical features and risk factors were recorded in a standardised form, categorised into subgroups, and analysed using descriptive statistics and diagnostic performance indicators, such as sensitivity, specificity and likelihood ratios. RESULTS: For 218/1273 individuals diagnosed with stroke, the three features with the highest positive likelihood ratio were the presence of diffusion weighted imaging positive lesion on magnetic resonance imaging (23.66, 95% confidence interval (CI) 14.35-51.08), extracranial carotid atherosclerosis (3.98, 95% CI 1.19-6.87) and a history of peripheral vascular disease (3.33, 95% CI 1.64-6.27). For TIA, the three features with the highest positive likelihood ratio were extracranial carotid atherosclerosis (3.98, 95% CI 1.19-8.27), presence of atrial fibrillation (2.43, 95% CI 1.54-3.46) and pre-existing anticoagulant therapy (2.39, 95% CI 1.61-3.29). For stroke and TIA, the respective features with the lowest negative likelihood ratios were limb weakness (0.71, 95% CI 0.65-0.77) and hypertension (0.66, 95% CI 0.49-0.84). CONCLUSIONS: The present study demonstrated that specific clinical features and risk factors were associated with the final diagnosis at TIA clinic. These clinical features may assist with diagnosis of TIA in centres without access to a vascular neurologist.

Manganese Neurotoxicity as a Stroke Mimic: A Case Report.

Manganese (Mn)-induced cerebral toxicity is a rare neurological condition that can present as a stroke mimic in high-risk populations. We present a case of a 40-year-old male with no known comorbidities who was brought to the emergency department with complaints of nonprogressive slurred speech and left facial weakness for eight days. Further history revealed that he had been working as a welder in a steel factory for the past seven years without using proper personal protective equipment (PPE). On physical examination, an upper motor neuron (UMN) type weakness on the left side of his face and spastic dysarthria could be appreciated. Following a brain computed tomography (CT) scan that showed ill-defined hypodensities in the basal ganglia without any signs of a hemorrhage, he was admitted to the stroke unit for conservative management and further investigations. A magnetic resonance imaging (MRI) scan of the brain done later showed features of manganese deposition and absorption in the globus pallidus and corticospinal tracts, indicating a diagnosis of manganese-induced cerebral toxicity. His serum manganese levels obtained during admission were normal. He was managed conservatively with intravenous rehydration and was discharged after symptomatic improvement. He was counseled and educated regarding the importance of wearing protective equipment while at work to reduce further exposure to the metal. During his follow-up visit, his symptoms had considerably improved with proper adherence to workplace safety measures.

Intracranial Myeloid Sarcoma Mimicking Hypertensive Intracerebral Hemorrhage.

We herein report a case of intracranial myeloid sarcoma mimicking hypertensive intracerebral hemorrhage. A 71-year-old man with a history of acute myeloid leukemia was admitted with acute-onset dysarthria. A hematoma-like lesion was found on computed tomography in the left putamen. Magnetic resonance imaging (MRI) and cerebrospinal fluid cytology confirmed the diagnosis of intracranial myeloid sarcoma. The patient showed a favorable response to chemotherapy, and follow-up MRI revealed shrinkage of the tumor. Since the computed tomography findings resemble those of intracerebral hemorrhage, it is important to suspect intracranial neoplasm, particularly in cases with a history of hematologic diseases.

Hypoglycemic hemineglect a stroke mimic.

Acute hypoglycemia may mimic acute ischemic stroke, but to our knowledge this has never been reported as transient hemineglect syndrome. We present a 60-year-old male with known diabetes mellitus who was brought to the hospital as a stroke alert. The patient had undetectable glucose levels upon arrival of emergency medical services (EMS), therefore hypertonic glucose was given. On our assessment in the emergency department (ED)he turned his head to the right side, looking to the right to answer questions when addressed on his left side. The extinction and neglect assessment revealed left-sided extinction on double tactile and visual stimulation. CT perfusion of the brain showed a decreased perfusion in the right cortical area. Given the unclear last known normal, urgent brain magnetic resonance imaging (MRI) was performed; stroke was excluded. The patient was admitted to the Intensive Care Unit where glucose was closely monitored. Electroencephalogram showed absence of seizure or postictal activity. The following morning, the patient returned to baseline and was able to recall the event. The episode was attributed to the severe hypoglycemia because of a recent medication change.

Rural versus metropolitan comparison of processes of care in the community-based management of TIA and minor stroke in Australia (an analysis from the INSIST study).

OBJECTIVES: To compare processes of care and clinical outcomes of community-based management of TIAs and minor strokes (TIAMS) between rural and metropolitan Australia. DESIGN: Inception cohort study between 2012 and 2016 with 12-month follow-up after index event (sub-study of INSIST). SETTING: Hunter and Manning valley regions of New South Wales, within the referral territory of the John Hunter Hospital Acute Neurovascular Clinic (JHHANC). PARTICIPANTS: Consecutive patients of 16 participating general practices, presenting with possible TIAMS to either primary or secondary care. MAIN OUTCOME MEASURES: Processes of care (referrals, key management processes, time-based metrics) and clinical outcomes. RESULTS: Of 613 participants with possible TIAMS who completed the baseline interview, 298 were adjudicated as having TIAMS (119 from rural, 179 from metropolitan). Mean age was 72.3 years (SD, 10.7) and 127 (43%) were women. Rural participants were more likely to be managed solely by a general practitioner (GP) than metropolitan participants (34% v 20%) and less likely to be referred to a JHHANC specialist (13% v 38%) or have brain magnetic resonance imaging (MRI) [24% v 51%]. Those rural participants who were referred, also waited longer (both p < 0.001). Recurrent stroke, myocardial infarction and death at 12 months were not significantly different between rural and metropolitan participants. CONCLUSIONS: Although TIAMS prognosis in rural settings where solely GP care is common is very good, the processes of care in such areas are inferior to metropolitan. This suggests there is further scope to support rural GPs to optimise care of TIAMS patients.

Jamaican Susumber Berry Poisoning Mimicking Acute Stroke.

BACKGROUND: Stroke mimics are non-vascular conditions that present with acute focal neurological deficits, simulating an acute ischemic stroke. Susumber berry (SB) toxicity is a rare cause of stroke mimic with limited case reports available in the literature. OBJECTIVES: We report four new cases of SB toxicity presenting as stroke mimic, and we performed a systematic review. METHODS: MEDLINE/EMBASE/WoS were searched for "susumber berries," "susumber," or "solanum torvum." RESULTS: 531 abstracts were screened after removal of duplicates; 5 articles and 2 conference abstracts were selected describing 13 patients. A total of 17 patients who ingested SB and became ill were identified, including our 4 patients. All but one presented with acute neurologic manifestation; 16 (94%) presented with dysarthria, 16 (94%) with unstable gait, 8 (47%) with nystagmus/gaze deviation, 10 (59%) with blurry vision, and 5 (29%) with autonomic symptoms. Six (35%) required ICU admission, and 3 (18%) were intubated. Fourteen (82%) had a rapid complete recovery, and 3 were hospitalized up to 1 month. CONCLUSIONS: SB toxicity can cause neurological symptoms that mimic an acute stroke typically with a posterior circulation symptom complex. Altered SB toxins (from post-harvest stressors or temperature changes) might stimulate muscarinic/nicotinic cholinergic receptors or inhibit acetylcholinesterase, causing gastrointestinal, neurological, and autonomic symptoms. In cases of multiple patients presenting simultaneously to the ED with stroke-like symptoms or when stroke-like symptoms fail to localize, a toxicological etiology (such as SB toxicity) should be considered.

Clinical application of brain perfusion imaging in detecting stroke mimics: A review.

Stroke mimics constitute a significant proportion of patients with suspected acute ischemic stroke. These conditions may resemble acute ischemic stroke and demonstrate abnormalities on perfusion imaging sequences. The most common stroke mimics include seizure/epilepsy, migraine with aura, brain tumors, functional disorders, infectious encephalopathies, Wernicke's encephalopathy, and metabolic abnormalities. Brain perfusion imaging techniques, particularly computed tomography perfusion and magnetic resonance perfusion, are being widely used in routine clinical practice for treatment selection in patients presenting with large vessel occlusion. At the same time, the utilization of these imaging modalities enables the opportunity to better diagnose patients with stroke mimics in a time-sensitive setting, leading to appropriate management, decision-making, and resource allocation. In this review, we describe patterns of perfusion abnormalities that could discriminate patients with stroke mimics from those with acute ischemic stroke and provide specific case examples to illustrate these perfusion abnormalities. In addition, we discuss the challenges associated with interpretation of perfusion images in stroke-related pathologies. In general, perfusion imaging can provide additional information in some cases-when used in combination with conventional magnetic resonance imaging and computed tomography-and might help in detecting stroke mimics among patients who present with acute onset focal neurological symptoms.

Imaging of Suspected Stroke in Children, From the AJR Special Series on Emergency Radiology.

Pediatric stroke encompasses different causes, clinical presentations, and associated conditions across ages. Although it is relatively uncommon, pediatric stroke presents with poor short- and long-term outcomes in many cases. Because of a wide range of overlapping presenting symptoms between pediatric stroke and other more common conditions, such as migraine and seizures, stroke diagnosis can be challenging or delayed in children. When combined with a comprehensive medical history and physical examination, neuroimaging plays a crucial role in diagnosing stroke and differentiating stroke mimics. This review highlights the current neuroimaging workup for diagnosing pediatric stroke in the emergency department, describes advantages and disadvantages of different imaging modalities, highlights disorders that predispose children to infarct or hemorrhage, and presents an overview of stroke mimics. Key differences in the initial approach to suspected stroke between children and adults are also discussed.