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Review article| Volume 93, P174-182, November 2021

Ischemic stroke mimics: A comprehensive review

Open AccessDOI:https://doi.org/10.1016/j.jocn.2021.09.025
Ischemic stroke mimics: A comprehensive review
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      Highlights

      • •
        Peripheral vertigo, toxic/metabolic changes, seizure, migraine and functional disorders are the most common stroke mimics.
      • •
        One out of four mimics is thrombolyzed with a very good outcome.
      • •
        Patient evaluation by should be carried by physicians experienced in the diagnosis of both ischemic stroke stroke and mimics.

      Abstract

      Background

      Ischemic stroke is the leading cause of disability and one of the leading causes of death. Ischemic stroke mimics (SMs) can account for a noteble number of diagnosed acute strokes and even can be thrombolyzed.

      Methods

      The aim of our comprehensive review was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of SMs in stroke/thrombolysis situations.

      Results

      Overall, 61 studies were selected with 62.664 participants. Ischemic stroke mimic rate was 24.8% (15044/60703). Most common types included peripheral vestibular dysfunction in 23.2%, toxic/metabolic in 13.2%, seizure in 13%, functional disorder in 9.7% and migraine in 7.76%. Ischemic stroke mimic have less vascular risk factors, younger age, female predominance, lower (nearly normal) blood pressure, no or less severe symptoms compared to ischemic stroke patients (p < 0.05 in all cases). 61.7% of ischemic stroke patients were thrombolysed vs. 26.3% among SMs (p < 0.001). (p < 0.001). Overall intracranial hemorrhage was reported in 9.4% of stroke vs. 0.7% in SM patients (p < 0.001). Death occurred in 11.3% of stroke vs 1.9% of SM patients (p < 0.001). Excellent outcome was (mRS 0–1) was reported in 41.8% ischemic stroke patients vs. 68.9% SMs (p < 0.001). Apart from HINTS manouvre or Hoover sign there is no specific method in the identification of mimics. MRI DWI or perfusion imaging have a role in the setup of differential diagnosis, but merit further investigation.

      Conclusion

      Our article is among the first complex reviews focusing on ischemic stroke mimics. Although it underscores the safety of thrombolysis in this situation, but also draws attention to the need of patient evaluation by physicians experienced in the diagnosis of both ischemic stroke and SMs, especially in vertigo, headache, seizure and conversional disorders.

      Keywords

      1. Introduction

      Ischemic stroke is the leading cause of disability and one of the leading causes of death. Enourmous efforts have been recently made to improve the clinical outcome of stroke patients including testing up comprehensive stroke units and the introducting endovascular procedures [
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      ]. The benefit of revascularisation procedures (both intravenous thrombolysis and endovascular procedures) is time-dependent, therefore shortening door-to-needle time is crucial in the emergency department [
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      ]. Ischemic stroke is usually an exclusionary clinical diagnosis in the emergency room, usually supported by noncontrast computed tomography (NCCT), which is the first step in the evaluation of ischemic stroke patients due to its widespread availability and relatively short imaging time [
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      2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49:e46–e99.

      ].
      However, the increased availability of systemic thrombolysis and shortened door-to-needle time have lead to inappropiate inclusion and treatment of so-called ischemic stroke mimics (ie. non-stroke patients) [
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      ]. Ischemic stroke mimics can account for approximately one in five clinically diagnosed acute ischemic strokes and the rate of thrombolyzed mimics can be as high as 17% [
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      ]. Based on literature data mimics are most likely to be identified as seizures, complicated migraines or conversion disorders [
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      ].
      Multimodal patient imaging (both CT and MR perfusion techniques) is an important part of acute ischemic stroke imaging to delineate the infarct from ischemic penumbra in specific situations such as stroke of unknown time of onset (SUTO) or in endovascular intervention with extended time window [
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      ]. Perfusion techniques may play a vital role in diagnosing SMs in the stroke/thrombolysis pathway (if the etiology is doubtful) [
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      CNS Spectr. 2020; 25: 101-113
      ,
      • Vilela P.
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      Eur J Radiol. 2017; 96: 133-144
      ].
      Despite of increasing number of publications in the last three decades, no comprehensive review has summarized the complex etiology, potential maltreatment and outcome of ischemic stroke mimics, especially in emergency situations.
      The aim of our review article was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of mimics in ischemic stroke/thrombolysis situations.

      2. Methods

      We searched PubMed, MEDLINE, and the Cochrane Library restricted to English language publications to January 2020. We used these search items in the following combinations: stroke, ischemic stroke, mimic, thrombolysis, rt-PA, alteplase, imaging, outcome, and mortality. After reviewing the abstracts, we obtained and reviewed the full text and reference lists of relevant articles.

      3. Statistical analysis

      Participants of the relevant studies were divided into two groups: (1) ischemic stroke patients, and (2) ischemic stroke mimics. Ischemic stroke mimic types, clinical findings, risk factors, thrombolysis rates and outcomes were compared between the two groups. Data were evaluated as means ± SD (standard deviation) by Student’s t-test or chi square test to detect significant differences among the examined parameters. Data analysis was performed using SPSS (version 22.0, IBM, New York, NY, USA).

      4. Results

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      • Croteau N.S.
      • et al.
      SpecTRA Study Group. White Matter Hyperintensity Volume Influences Symptoms in Patients Presenting With Minor Neurological Deficits.
      Stroke. 2020; 51: 409-415
      ,
      • Whiteley W.N.
      • Wardlaw J.M.
      • Dennis M.S.
      • Sandercock P.A.G.
      Clinical scores for the identification of stroke and transient ischaemic attack in the emergency department: a cross-sectional study.
      J Neurol Neurosurg Psychiatry. 2011; 82: 1006-1010
      ,
      • Yaghi S.
      • Rayaz S.
      • Bianchi N.
      • Hall-Barrow J.C.
      • Hinduja A.
      Thrombolysis to stroke mimics in telestroke.
      J Telemed Telecare. 2012; https://doi.org/10.1258/jtt.2012.120510
      ,
      • Wilkins S.S.
      • Bourke P.
      • Salam A.
      • Akhtar N.
      • D'Souza A.
      • Kamran S.
      • et al.
      Functional Stroke Mimics: Incidence and Characteristics at a Primary Stroke Center in the Middle East.
      Psychosom Med. 2018; 80: 416-421
      ]. There were five prospective multicenter, one observational prospective, 17 prospective single center, 9 retrospective multicenter and 30 retrospective single center study (Supplementary Table 1).
      Stroke mimic rate was 24.9% overall (15595/62664). Stroke mimic rate based on study type can be seen in Supplementary Table 1.

      4.1 Mimic types

      Ischemic stroke mimic types were the following: peripheral vestibular dysfunction in 23.2% (1109/4769 based on 15 studies /11, 16, 22, 26, 30, 32, 44, 46, 51, 61,65, 66, 69, 70, 71/), toxic/metabolic in 13.2% (1053/7985, based on 15 studies /11, 16, 22, 26, 30, 32, 44, 46, 51, 61, 65, 66, 69, 70, 71/), seizure in 13% (1257/9629, based on 11 studies /11, 25, 26, 28, 32, 33, 36, 53, 64, 68, 71/), functional disorder in 9.7% (373/3822 based on 12 studies /11, 14, 16, 17, 22, 41, 51, 59, 61, 69, 70, 71/) and migraine in 7.76% (697/8983, based on 36 studies /11, 14, 16, 17, 18, 20, 22–25, 27, 28, 30, 32, 33–47, 71/). Other etiologies were collapse/presyncope in 5.95% (464/7858 /11, 16, 18, 20, 22, 25–27, 30, 32, 35, 37, 38, 43, 44, 46, 47, 51, 53, 54, 59, 61, 62, 66, 69, 70/), sepsis in 5.3% (265/4823 /11, 16, 17, 23–25, 32, 33, 37, 38, 42, 43, 54, 60, 61, 69, 70,71/), mononeuropathy in 5% (including those with Bell's palsy, radial nerve palsy, oculomotor or abducens nerve palsies, but proper data are lacking) (162/3213 /11, 14, 16, 41, 61, 66, 70/), space-occupying lesion in 4.3% (299/6897 /11,16–18, 24, 26–28, 30, 34, 37, 38, 43, 46–48, 51, 54, 61, 64–66, 69, 70/), acute confusion in 1.9% (84/4344 /11, 14, 16, 34, 38, 44, 59, 70/). dementia in 1.2% (54/4577 /11, 16, 23, 33, 34, 38, 43, 46, 51, 54, 55, 61, 69, 70/) and spinal lesion in 0.7% (22/2939 /11, 16, 20, 25, 43, 61/) (Fig. 2). 9.69 % had non defined etiology which was not entirely clarified including Susac syndrome, obstructive hydrocephalus, transient global amnesia etc. (Fig. 1).
      Figure thumbnail gr1
      Fig. 1Etiology of stroke mimics (%).
      Figure thumbnail gr2
      Fig. 2Clinical findings in the examined subgroups (%). Abbreviations: WOS: woke up symptoms, LOC: loss of consciousness, ATW: able to walk. *p < 0.05.

      4.2 Clinical findings

      SM patients had significantly lower NIHSS (4.99 ± 5.65 vs. 8.06 ± 6.37, p < 0.001 /11, 14, 15, 19, 20–22, 24, 26, 28, 30, 34, 37, 41, 42, 45, 47, 49, 52, 53, 55, 58, 59, 61, 63–67, 69, 70/)), they were younger (60.9 ± 10.4 vs. 68.4 ± 9.7 years, p < 0.001 /11, 14, 15, 18–31, 33–50, 52, 53, 55–59, 61–71/) with female predominance (68 vs 56 %, p < 0.001 /11, 14, 15, 17–30, 32–53, 5–57, 59, 61–71/). The median time to onset from presentation was not significant between SM and ischemic stroke patients (116.75 ± 53.03 vs. 134.45 ± 58.27 min, p = 0.5 /11, 22, 26, 30, 31, 41, 42, 55, 56, 65, 70/).
      Average blood pressure was 153.75/86.45 Hgmm in ischemic stroke and 140.25/83.1 Hgmm in SM patients (p < 0.001) [

      Pearson C, Przyklenk K, Mika VH, Ayaz SI, Ellis M, Varade P, Tolomello R, Welch RD. Utility of point of care assessment of platelet reactivity (using the PFA-100®) to aid in diagnosis of stroke. Am J Emerg Med. 2017;35(5):802.e1‐802.e5.

      ,
      • Lewandowski C.
      • Mays-Wilson K.
      • Miller J.
      • Penstone P.
      • Miller D.J.
      • Bakoulas K.
      • et al.
      Safety and outcomes in stroke mimics after intravenous tissue plasminogen activator administration: a single-center experience.
      J Stroke Cerebrovasc Dis. 2015; 24: 48-52
      ,
      • Sivakumaran P.
      • Gill D.
      • Mahir G.
      • Baheerathan A.
      • Kar A.
      A Retrospective Cohort Study on the Use of Intravenous Thrombolysis in Stroke Mimics.
      J Stroke Cerebrovasc Dis. 2016; 25: 1057-1061
      ,
      • Amort M.
      • Fluri F.
      • Schäfer J.
      • Weisskopf F.
      • Katan M.
      • Burow A.
      • et al.
      Transient ischemic attack versus transient ischemic attack mimics: frequency, clinical characteristics and outcome.
      Cerebrovasc Dis. 2011; 32: 57-64
      ,
      • Suzuki J.
      • Nakai N.
      • Kondo N.
      • Tsuji H.
      • Inagaki R.
      • Furukawa S.
      • et al.
      Ten-Year Evaluation of the TOYOTA Prehospital Stroke Scale for Tissue Plasminogen Activator Intravenous Therapy in the Real World.
      Cerebrovasc Dis. 2018; 46: 184-192
      ,
      • Okano Y.
      • Ishimatsu K.
      • Kato Y.
      • Yamaga J.
      • Kuwahara K.
      • Okumoto K.
      • et al.
      Clinical features of stroke mimics in the emergency department.
      Acute Med Surg. 2018; 5: 241-248
      ,
      • Bath P.M.
      • Scutt P.
      • Appleton J.P.
      • Dixon M.
      • Woodhouse L.J.
      • Wardlaw J.M.
      • et al.
      Baseline characteristics of the 1149 patients recruited into the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) randomized controlled trial.
      Int J Stroke. 2019; 14: 298-305
      ,
      • Bliden K.P.
      • Raviv G.
      • Tantry U.S.
      • Chaudhary R.
      • Cochran J.W.
      • Navarese E.P.
      • et al.
      “Blueprinting” thrombogenicity and antithrombotic drug response at the bedside in patients presenting emergently with symptoms of acute stroke.
      J Thromb Thrombolysis. 2019; 47: 192-199
      ,
      • Kvistad C.E.
      • Novotny V.
      • Næss H.
      • Hagberg G.
      • Ihle-Hansen H.
      • Waje-Andreassen U.
      • et al.
      Safety and predictors of stroke mimics in The Norwegian Tenecteplase Stroke Trial (NOR-TEST).
      Int J Stroke. 2019; 14: 508-516
      ,
      • Zinkstok S.M.
      • Engelter S.T.
      • Gensicke H.
      • Lyrer P.A.
      • Ringleb P.A.
      • Artto V.
      • et al.
      Safety of thrombolysis in stroke mimics: results from a multicenter cohort study.
      Stroke. 2013; 44: 1080-1084
      ,
      • Chang P.
      • Ruff I.
      • Mendelson S.J.
      • Caprio F.
      • Bergman D.L.
      • Prabhakaran S.
      The 2CAN Score.
      Stroke. 2018; 49: 2866-2871
      ]. Unrevealed AF on admission was 15.6 % (17/109) in SM and 24.6 % (55/224) in ischemic stroke patients based on one study (p = 0.06) [
      • Hand P.J.
      • Kwan J.
      • Lindley R.I.
      • Dennis M.S.
      • Wardlaw J.M.
      Distinguishing between stroke and mimic at the bedside: the brain attack study.
      Stroke. 2006; 37: 769-775
      ] (Table 1).
      Table 1Clinical findings in the examined subgroups.
      StrokeStroke mimicp value
      NIHSS (points)8.06 ± 6.374.99 ± 5.65<0.001
      Age (years)68.4 ± 9.760.9 ± 10.4<0.001
      Female gender (%)56%68%<0.001
      Median time (min)134.45 ± 58.27116.75 ± 53.030.5
      Blood pressure (Hgmm)153.75/86.45140.25/83.1<0.001
      Unrevealed atrial fibrillation (%)24.615.60.06
      Woke up symptoms were presented in 27.9% (211/757) in SM vs. 24.6% (278/1132) in ischemic stroke patients (p = 0.1 /11, 38, 61, 62/). Loss of consciousness was more common in SM (14.7%, 275/1876) than in ischemic stroke (10.2%, 390/3831) patients (p < 0.001 /11, 28, 34, 45, 46, 49, 52, 62, 64, 69/). Vomiting was also more common in SM patients 28.5% (162/569) vs. 18.8% (73/388) (p < 0.001 /11, 17, 36, 62/). Headache occured more frequently in SM patients 21.3% (269/1263) vs. 9.8% (202/2061) (p < 0.001) [
      • Hand P.J.
      • Kwan J.
      • Lindley R.I.
      • Dennis M.S.
      • Wardlaw J.M.
      Distinguishing between stroke and mimic at the bedside: the brain attack study.
      Stroke. 2006; 37: 769-775
      ,
      • DeLaroche A.M.
      • Sivaswamy L.
      • Farooqi A.
      • Kannikeswaran N.
      Pediatric Stroke and Its Mimics: Limitations of a Pediatric Stroke Clinical Pathway.
      Pediatr Neurol. 2018; 80: 35-41
      ,
      • Sharma R.
      • Macy S.
      • Richardson K.
      • Lokhnygina Y.
      • Laskowitz D.T.
      A blood-based biomarker panel to detect acute stroke.
      J Stroke Cerebrovasc Dis. 2014; 23: 910-918
      ,
      • Ifergan H.
      • Amelot A.
      • Ismail M.
      • Gaudron M.
      • Cottier J.P.
      • Narata A.P.
      Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials.
      Arq Neuropsiquiatr. 2020; 78: 88-95
      ,
      • Amort M.
      • Fluri F.
      • Schäfer J.
      • Weisskopf F.
      • Katan M.
      • Burow A.
      • et al.
      Transient ischemic attack versus transient ischemic attack mimics: frequency, clinical characteristics and outcome.
      Cerebrovasc Dis. 2011; 32: 57-64
      ,
      • Quenardelle V.
      • Lauer-Ober V.
      • Zinchenko I.
      • Bataillard M.
      • Rouyer O.
      • Beaujeux R.
      • et al.
      Stroke Mimics in a Stroke Care Pathway Based on MRI Screening.
      Cerebrovasc Dis. 2016; 42: 205-212
      ,
      • Michelson E.A.
      • Hanley D.
      • Chabot R.
      • Prichep L.S.
      • Goldstein J.
      Identification of acute stroke using quantified brain electrical activity.
      Acad Emerg Med. 2015; 22: 67-72
      ,
      • Esmaeili S.
      • Afrakhteh M.
      • Bahadori M.
      • Shojaei S.F.
      • Ashayeri R.
      • Mehrpour M.
      Thrombolytic treatment in stroke mimic, inevitable but fortunately safe: An observational study from Iran.
      Iran J Neurol. 2019; 18: 172-175
      ] and more of them were able to walk comparing to ischemic stroke patients: 51.38% (56/109) vs. 37.5% (84/224) (p = 0.016) although it was based on the results of one study [
      • Hand P.J.
      • Kwan J.
      • Lindley R.I.
      • Dennis M.S.
      • Wardlaw J.M.
      Distinguishing between stroke and mimic at the bedside: the brain attack study.
      Stroke. 2006; 37: 769-775
      ]. Glasgow Coma Scale (GCS) < 15 was 91.9% (1152/1267) in ischemic stroke and 88.8% (688/775) in SM patients (p = 0.43) [
      • Hand P.J.
      • Kwan J.
      • Lindley R.I.
      • Dennis M.S.
      • Wardlaw J.M.
      Distinguishing between stroke and mimic at the bedside: the brain attack study.
      Stroke. 2006; 37: 769-775
      ,
      • Sharma R.
      • Macy S.
      • Richardson K.
      • Lokhnygina Y.
      • Laskowitz D.T.
      A blood-based biomarker panel to detect acute stroke.
      J Stroke Cerebrovasc Dis. 2014; 23: 910-918
      ,
      • Bath P.M.
      • Scutt P.
      • Appleton J.P.
      • Dixon M.
      • Woodhouse L.J.
      • Wardlaw J.M.
      • et al.
      Baseline characteristics of the 1149 patients recruited into the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) randomized controlled trial.
      Int J Stroke. 2019; 14: 298-305
      ,
      • Mackay M.T.
      • Yock-Corrales A.
      • Churilov L.
      • Monagle P.
      • Donnan G.A.
      • Babl F.E.
      Differentiating Childhood Stroke From Mimics in the Emergency Department.
      Stroke. 2016; 47: 2476-2481
      ].
      Confusion could be detected in 11.2% (87/775) in SM and 8.9% (115/1284) in ischemic stroke patients (p = 0.09) [
      • Hand P.J.
      • Kwan J.
      • Lindley R.I.
      • Dennis M.S.
      • Wardlaw J.M.
      Distinguishing between stroke and mimic at the bedside: the brain attack study.
      Stroke. 2006; 37: 769-775
      ,
      • Asaithambi G.
      • Castle A.L.
      • Sperl M.A.
      • Ravichandran J.
      • Gupta A.
      • Ho B.M.
      • et al.
      Thrombolytic treatment to stroke mimic patients via telestroke.
      Clin Neurol Neurosurg. 2017; 153: 5-7
      ,
      • Kim S.J.
      • Kim D.W.
      • Kim H.Y.
      • Roh H.G.
      • Park J.-J.
      Seizure in code stroke: Stroke mimic and initial manifestation of stroke.
      Am J Emerg Med. 2019; 37: 1871-1875
      ,
      • Quenardelle V.
      • Lauer-Ober V.
      • Zinchenko I.
      • Bataillard M.
      • Rouyer O.
      • Beaujeux R.
      • et al.
      Stroke Mimics in a Stroke Care Pathway Based on MRI Screening.
      Cerebrovasc Dis. 2016; 42: 205-212
      ,
      • Hansson P.-O.
      • Andersson Hagiwara M.
      • Herlitz J.
      • Brink P.
      • Wireklint Sundström B.
      Prehospital assessment of suspected stroke and TIA: An observational study.
      Acta Neurol Scand. 2019; 140: 93-99
      ,
      • Dawson A.
      • Cloud G.C.
      • Pereira A.C.
      • Moynihan B.J.
      Stroke mimic diagnoses presenting to a hyperacute stroke unit.
      Clin Med (Lond). 2016; 16: 423-426
      ,
      • Avellaneda-Gómez C.
      • Rodríguez Campello A.
      • Giralt Steinhauer E.
      • Gómez González A.
      • Serra Martínez M.
      • de Ceballos C.P.
      • et al.
      Description of stroke mimics after complete neurovascular assessment.
      Neurologia. 2019; 34: 7-13
      ,
      • Yaghi S.
      • Rayaz S.
      • Bianchi N.
      • Hall-Barrow J.C.
      • Hinduja A.
      Thrombolysis to stroke mimics in telestroke.
      J Telemed Telecare. 2012; https://doi.org/10.1258/jtt.2012.120510
      ]. No signs of stroke on physical examination could be found 33.7% (131/389) in SM and 10.5% (36/343) in ischemic stroke patients (p < 0.001) (Fig. 2).
      CT was diagnostic in 80.2% (3481/4338) in ischemic stroke and 57.8% (884/1529) in SM patiens (p < 0.001 /11, 25, 26, 28, 32, 33, 36, 53, 64, 68/), while MRI was carried out in 41.5% (3098/7470) in ischemic stroke and 50% (787/1575) in SM patients (p < 0.001 /11,25,26,28, 32, 33, 36, 53, 59, 61, 64/). CT perfusion may help to differentiate between ischemic stroke and SM patients based on two studies [
      • Hopyan J.
      • Ciarallo A.
      • Dowlatshahi D.
      • Howard P.
      • John V.
      • Yeung R.
      • et al.
      Certainty of stroke diagnosis: incremental benefit with CT perfusion over noncontrast CT and CT angiography.
      Radiology. 2010; 255: 142-153
      ,
      • Siegler J.E.
      • Rosenberg J.
      • Cristancho D.
      • Olsen A.
      • Pulst-Korenberg J.
      • Raab L.
      • et al.
      Computed tomography perfusion in stroke mimics.
      Int J Stroke. 2020; 15: 299-307
      ]. CT perfusion was more likely to enable confirmation of clinical ischemic stroke diagnosis (odds ratio, 13.3) than was noncontrast CT and CT angiography (odds ratio, 6.4) or noncontrast CT alone (odds ratio, 3.3) [
      • Hopyan J.
      • Ciarallo A.
      • Dowlatshahi D.
      • Howard P.
      • John V.
      • Yeung R.
      • et al.
      Certainty of stroke diagnosis: incremental benefit with CT perfusion over noncontrast CT and CT angiography.
      Radiology. 2010; 255: 142-153
      ].

      4.3 Risk factors

      Hypertension 66.8% (20074/30035) vs. 41.1% (3434/8347) [
      • Hand P.J.
      • Kwan J.
      • Lindley R.I.
      • Dennis M.S.
      • Wardlaw J.M.
      Distinguishing between stroke and mimic at the bedside: the brain attack study.
      Stroke. 2006; 37: 769-775
      ,
      • Asaithambi G.
      • Castle A.L.
      • Sperl M.A.
      • Ravichandran J.
      • Gupta A.
      • Ho B.M.
      • et al.
      Thrombolytic treatment to stroke mimic patients via telestroke.
      Clin Neurol Neurosurg. 2017; 153: 5-7
      ,

      Pearson C, Przyklenk K, Mika VH, Ayaz SI, Ellis M, Varade P, Tolomello R, Welch RD. Utility of point of care assessment of platelet reactivity (using the PFA-100®) to aid in diagnosis of stroke. Am J Emerg Med. 2017;35(5):802.e1‐802.e5.

      ,
      • Sharma R.
      • Macy S.
      • Richardson K.
      • Lokhnygina Y.
      • Laskowitz D.T.
      A blood-based biomarker panel to detect acute stroke.
      J Stroke Cerebrovasc Dis. 2014; 23: 910-918
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      • Lewandowski C.
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      • Miller J.
      • Penstone P.
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      • Bakoulas K.
      • et al.
      Safety and outcomes in stroke mimics after intravenous tissue plasminogen activator administration: a single-center experience.
      J Stroke Cerebrovasc Dis. 2015; 24: 48-52
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      • Goyal N.
      • Male S.
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      • Zand R.
      Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment.
      J Stroke Cerebrovasc Dis. 2015; 24: 828-833
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      Stroke Mimics Transported by Emergency Medical Services to a Comprehensive Stroke Center: The Magnitude of the Problem.
      J Stroke Cerebrovasc Dis. 2018; 27: 2738-2745
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      • Garg R.
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      Stroke Mimics: An Important Source of Bias in Acute Ischemic Stroke Research.
      J Stroke Cerebrovasc Dis. 2019; 28: 2475-2480
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      • Ifergan H.
      • Amelot A.
      • Ismail M.
      • Gaudron M.
      • Cottier J.P.
      • Narata A.P.
      Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials.
      Arq Neuropsiquiatr. 2020; 78: 88-95
      ,
      • Okano Y.
      • Ishimatsu K.
      • Kato Y.
      • Yamaga J.
      • Kuwahara K.
      • Okumoto K.
      • et al.
      Clinical features of stroke mimics in the emergency department.
      Acute Med Surg. 2018; 5: 241-248
      ,
      • Hansson P.-O.
      • Andersson Hagiwara M.
      • Herlitz J.
      • Brink P.
      • Wireklint Sundström B.
      Prehospital assessment of suspected stroke and TIA: An observational study.
      Acta Neurol Scand. 2019; 140: 93-99
      ,
      • Geisler F.
      • Ali S.F.
      • Ebinger M.
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      Evaluation of a score for the prehospital distinction between cerebrovascular disease and stroke mimic patients.
      Int J Stroke. 2019; 14: 400-408
      ,
      • Noureddine A.
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      Differentiation of true transient ischemic attack versus transient ischemic attack mimics.
      Iran J Neurol. 2014; 13: 127-130
      ,
      • Williams J.B.
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      • Campos B.
      Endothelial microparticle levels are similar in acute ischemic stroke and stroke mimics due to activation and not apoptosis/necrosis.
      Acad Emerg Med. 2007; 14: 685-690
      ,
      • Ali S.F.
      • Viswanathan A.
      • Singhal A.B.
      • Rost N.S.
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      • et al.
      Partners Telestroke Network. The TeleStroke mimic (TM)-score: a prediction rule for identifying stroke mimics evaluated in a Telestroke Network.
      J Am Heart Assoc. 2014; 3https://doi.org/10.1161/JAHA.114.000838
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      • et al.
      Stroke Mimics Transported by Emergency Medical Services to a Comprehensive Stroke Center: The Magnitude of the Problem.
      J Stroke Cerebrovasc Dis. 2018; 27: 2738-2745
      ,
      • Natteru P.
      • Mohebbi M.R.
      • George P.
      • Wisco D.
      • Gebel J.
      • Newey C.R.
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      Stroke Res Treat. 2016; 2016: 1-6
      ,
      • Winkler D.T.
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      • Fuhr P.
      • Wetzel S.G.
      • Lyrer P.A.
      • Ruegg S.
      • et al.
      Thrombolysis in stroke mimics: frequency, clinical characteristics, and outcome.
      Stroke. 2009; 40: 1522-1525
      ,
      • Zinkstok S.M.
      • Engelter S.T.
      • Gensicke H.
      • Lyrer P.A.
      • Ringleb P.A.
      • Artto V.
      • et al.
      Safety of thrombolysis in stroke mimics: results from a multicenter cohort study.
      Stroke. 2013; 44: 1080-1084
      ,
      • Chang P.
      • Ruff I.
      • Mendelson S.J.
      • Caprio F.
      • Bergman D.L.
      • Prabhakaran S.
      The 2CAN Score.
      Stroke. 2018; 49: 2866-2871
      ,
      • Zerna C.
      • Yu A.Y.X.
      • Hong Z.M.
      • Penn A.M.
      • Lesperance M.L.
      • Croteau N.S.
      • et al.
      SpecTRA Study Group. White Matter Hyperintensity Volume Influences Symptoms in Patients Presenting With Minor Neurological Deficits.
      Stroke. 2020; 51: 409-415
      ,
      • Yaghi S.
      • Rayaz S.
      • Bianchi N.
      • Hall-Barrow J.C.
      • Hinduja A.
      Thrombolysis to stroke mimics in telestroke.
      J Telemed Telecare. 2012; https://doi.org/10.1258/jtt.2012.120510
      ,
      • Wilkins S.S.
      • Bourke P.
      • Salam A.
      • Akhtar N.
      • D'Souza A.
      • Kamran S.
      • et al.
      Functional Stroke Mimics: Incidence and Characteristics at a Primary Stroke Center in the Middle East.
      Psychosom Med. 2018; 80: 416-421
      ,
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      • Votova K.
      • Sedgwick C.
      • Balshaw R.F.
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      • et al.
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      BMC Neurol. 2019; 19https://doi.org/10.1186/s12883-019-1466-4
      ,
      • Uchino K.
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      ] were more common in ischemic stroke patients (p < 0.001 in all cases) (Table 2).
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      StrokeStroke mimicP values
      Smoking25.722.2<0.001
      Hypertension66.841.1<0.001
      Dyslipidaemia3823.6<0.001
      Diabetes24.317.8<0.001
      IHD15.99.1<0.001
      AF238.4<0.001
      PVD9.96.7<0.001
      Previous stroke19.319.70.42
      Cognitive impairment11.125.4<0.001
      Migraine in anamnesis11.316.5<0.001
      Seizure in anamnesis1.52.30.23
      Known malignancy8.79.10.88
      Abbreviations: IHD: ischemic heart disease, AF: atrial fibrillation, PVD: peripheral vascular disease.
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      Transient ischemic attack versus transient ischemic attack mimics: frequency, clinical characteristics and outcome.
      Cerebrovasc Dis. 2011; 32: 57-64
      ,
      • Quenardelle V.
      • Lauer-Ober V.
      • Zinchenko I.
      • Bataillard M.
      • Rouyer O.
      • Beaujeux R.
      • et al.
      Stroke Mimics in a Stroke Care Pathway Based on MRI Screening.
      Cerebrovasc Dis. 2016; 42: 205-212
      ,
      • Hansson P.-O.
      • Andersson Hagiwara M.
      • Herlitz J.
      • Brink P.
      • Wireklint Sundström B.
      Prehospital assessment of suspected stroke and TIA: An observational study.
      Acta Neurol Scand. 2019; 140: 93-99
      ,
      • Bliden K.P.
      • Raviv G.
      • Tantry U.S.
      • Chaudhary R.
      • Cochran J.W.
      • Navarese E.P.
      • et al.
      “Blueprinting” thrombogenicity and antithrombotic drug response at the bedside in patients presenting emergently with symptoms of acute stroke.
      J Thromb Thrombolysis. 2019; 47: 192-199
      ,
      • Kostulas N.
      • Larsson M.
      • Kall T.-B.
      • von Euler M.
      • Nathanson D.
      Safety of thrombolysis in stroke mimics: an observational cohort study from an urban teaching hospital in Sweden.
      BMJ Open. 2017; 7: e016311https://doi.org/10.1136/bmjopen-2017-016311
      ,
      • Williams J.B.
      • Jauch E.C.
      • Lindsell C.J.
      • Campos B.
      Endothelial microparticle levels are similar in acute ischemic stroke and stroke mimics due to activation and not apoptosis/necrosis.
      Acad Emerg Med. 2007; 14: 685-690
      ,
      • Ali S.F.
      • Viswanathan A.
      • Singhal A.B.
      • Rost N.S.
      • Forducey P.G.
      • Davis L.W.
      • et al.
      Partners Telestroke Network. The TeleStroke mimic (TM)-score: a prediction rule for identifying stroke mimics evaluated in a Telestroke Network.
      J Am Heart Assoc. 2014; 3https://doi.org/10.1161/JAHA.114.000838
      ,
      • Kvistad C.E.
      • Novotny V.
      • Næss H.
      • Hagberg G.
      • Ihle-Hansen H.
      • Waje-Andreassen U.
      • et al.
      Safety and predictors of stroke mimics in The Norwegian Tenecteplase Stroke Trial (NOR-TEST).
      Int J Stroke. 2019; 14: 508-516
      ,
      • Avellaneda-Gómez C.
      • Rodríguez Campello A.
      • Giralt Steinhauer E.
      • Gómez González A.
      • Serra Martínez M.
      • de Ceballos C.P.
      • et al.
      Description of stroke mimics after complete neurovascular assessment.
      Neurologia. 2019; 34: 7-13
      ,
      • Natteru P.
      • Mohebbi M.R.
      • George P.
      • Wisco D.
      • Gebel J.
      • Newey C.R.
      Variables That Best Differentiate In-Patient Acute Stroke from Stroke-Mimics with Acute Neurological Deficits.
      Stroke Res Treat. 2016; 2016: 1-6
      ,
      • Siegler J.E.
      • Rosenberg J.
      • Cristancho D.
      • Olsen A.
      • Pulst-Korenberg J.
      • Raab L.
      • et al.
      Computed tomography perfusion in stroke mimics.
      Int J Stroke. 2020; 15: 299-307
      ,
      • Zinkstok S.M.
      • Engelter S.T.
      • Gensicke H.
      • Lyrer P.A.
      • Ringleb P.A.
      • Artto V.
      • et al.
      Safety of thrombolysis in stroke mimics: results from a multicenter cohort study.
      Stroke. 2013; 44: 1080-1084
      ,
      • Chang P.
      • Ruff I.
      • Mendelson S.J.
      • Caprio F.
      • Bergman D.L.
      • Prabhakaran S.
      The 2CAN Score.
      Stroke. 2018; 49: 2866-2871
      ,
      • Zerna C.
      • Yu A.Y.X.
      • Hong Z.M.
      • Penn A.M.
      • Lesperance M.L.
      • Croteau N.S.
      • et al.
      SpecTRA Study Group. White Matter Hyperintensity Volume Influences Symptoms in Patients Presenting With Minor Neurological Deficits.
      Stroke. 2020; 51: 409-415
      ,
      • Wilkins S.S.
      • Bourke P.
      • Salam A.
      • Akhtar N.
      • D'Souza A.
      • Kamran S.
      • et al.
      Functional Stroke Mimics: Incidence and Characteristics at a Primary Stroke Center in the Middle East.
      Psychosom Med. 2018; 80: 416-421
      ,
      • Sharma R.
      • Macy S.
      • Richardson K.
      • Lokhnygina Y.
      • Laskowitz D.T.
      A blood-based biomarker panel to detect acute stroke.
      J Stroke Cerebrovasc Dis. 2014; 23: 910-918
      ,
      • Lewandowski C.
      • Mays-Wilson K.
      • Miller J.
      • Penstone P.
      • Miller D.J.
      • Bakoulas K.
      • et al.
      Safety and outcomes in stroke mimics after intravenous tissue plasminogen activator administration: a single-center experience.
      J Stroke Cerebrovasc Dis. 2015; 24: 48-52
      ,
      • Goyal N.
      • Male S.
      • Al Wafai A.
      • Bellamkonda S.
      • Zand R.
      Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment.
      J Stroke Cerebrovasc Dis. 2015; 24: 828-833
      ,
      • Liberman A.L.
      • Liotta E.M.
      • Caprio F.Z.
      • Ruff I.
      • Maas M.B.
      • Bernstein R.A.
      • et al.
      Do efforts to decrease door-to-needle time risk increasing stroke mimic treatment rates?.
      Neurol Clin Pract. 2015; 5: 247-252
      ,
      • Gioia L.C.
      • Zewude R.T.
      • Kate M.P.
      • Liss K.
      • Rowe B.H.
      • Buck B.
      • et al.
      Prehospital systolic blood pressure is higher in acute stroke compared with stroke mimics.
      Neurology. 2016; 86: 2146-2153
      ,
      • Merino J.G.
      • Luby M.
      • Benson R.T.
      • Davis L.A.
      • Hsia A.W.
      • Latour L.L.
      • et al.
      Predictors of acute stroke mimics in 8187 patients referred to a stroke service.
      J Stroke Cerebrovasc Dis. 2013; 22: e397-e403
      ].
      Cognitive impairment 25.4% (31/122) vs. 11.1% (40/359) [
      • Hand P.J.
      • Kwan J.
      • Lindley R.I.
      • Dennis M.S.
      • Wardlaw J.M.
      Distinguishing between stroke and mimic at the bedside: the brain attack study.
      Stroke. 2006; 37: 769-775
      ,
      • Asaithambi G.
      • Castle A.L.
      • Sperl M.A.
      • Ravichandran J.
      • Gupta A.
      • Ho B.M.
      • et al.
      Thrombolytic treatment to stroke mimic patients via telestroke.
      Clin Neurol Neurosurg. 2017; 153: 5-7
      ], and history of migraine 16.5% (151/916) vs. 11.3% (215/1900) [
      • Hand P.J.
      • Kwan J.
      • Lindley R.I.
      • Dennis M.S.
      • Wardlaw J.M.
      Distinguishing between stroke and mimic at the bedside: the brain attack study.
      Stroke. 2006; 37: 769-775
      ,
      • Asaithambi G.
      • Castle A.L.
      • Sperl M.A.
      • Ravichandran J.
      • Gupta A.
      • Ho B.M.
      • et al.
      Thrombolytic treatment to stroke mimic patients via telestroke.
      Clin Neurol Neurosurg. 2017; 153: 5-7
      ,

      Pearson C, Przyklenk K, Mika VH, Ayaz SI, Ellis M, Varade P, Tolomello R, Welch RD. Utility of point of care assessment of platelet reactivity (using the PFA-100®) to aid in diagnosis of stroke. Am J Emerg Med. 2017;35(5):802.e1‐802.e5.

      ,
      • Ifergan H.
      • Amelot A.
      • Ismail M.
      • Gaudron M.
      • Cottier J.P.
      • Narata A.P.
      Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials.
      Arq Neuropsiquiatr. 2020; 78: 88-95
      ,
      • Gargalas S.
      • Weeks R.
      • Khan-Bourne N.
      • Shotbolt P.
      • Simblett S.
      • Ashraf L.
      • et al.
      Incidence and outcome of functional stroke mimics admitted to a hyperacute stroke unit.
      J Neurol Neurosurg Psychiatry. 2017; 88: 2-6
      ,
      • Zerna C.
      • Yu A.Y.X.
      • Hong Z.M.
      • Penn A.M.
      • Lesperance M.L.
      • Croteau N.S.
      • et al.
      SpecTRA Study Group. White Matter Hyperintensity Volume Influences Symptoms in Patients Presenting With Minor Neurological Deficits.
      Stroke. 2020; 51: 409-415
      ] were more common is SM patients (p < 0.001 in both cases).
      History of seizures/epilepsy (1.5%, 13/871 vs. 2.3%, 15/643, p = 0.23) [
      • Hand P.J.
      • Kwan J.
      • Lindley R.I.
      • Dennis M.S.
      • Wardlaw J.M.
      Distinguishing between stroke and mimic at the bedside: the brain attack study.
      Stroke. 2006; 37: 769-775
      ,
      • Asaithambi G.
      • Castle A.L.
      • Sperl M.A.
      • Ravichandran J.
      • Gupta A.
      • Ho B.M.
      • et al.
      Thrombolytic treatment to stroke mimic patients via telestroke.
      Clin Neurol Neurosurg. 2017; 153: 5-7
      ,

      Pearson C, Przyklenk K, Mika VH, Ayaz SI, Ellis M, Varade P, Tolomello R, Welch RD. Utility of point of care assessment of platelet reactivity (using the PFA-100®) to aid in diagnosis of stroke. Am J Emerg Med. 2017;35(5):802.e1‐802.e5.

      ,
      • Ifergan H.
      • Amelot A.
      • Ismail M.
      • Gaudron M.
      • Cottier J.P.
      • Narata A.P.
      Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials.
      Arq Neuropsiquiatr. 2020; 78: 88-95
      ] and malignancy (8.7%, 21/241 vs. 9.1%, 10/109, p = 0.88) [
      • Hand P.J.
      • Kwan J.
      • Lindley R.I.
      • Dennis M.S.
      • Wardlaw J.M.
      Distinguishing between stroke and mimic at the bedside: the brain attack study.
      Stroke. 2006; 37: 769-775
      ] were not different in the two groups.
      Pre-existing psychological disturbace was more common in ischemic stroke vs. SM patients (12.5%, 233/1857 vs. 9.2%, 121/1318, p = 0.003) [
      • Hand P.J.
      • Kwan J.
      • Lindley R.I.
      • Dennis M.S.
      • Wardlaw J.M.
      Distinguishing between stroke and mimic at the bedside: the brain attack study.
      Stroke. 2006; 37: 769-775
      ,
      • Asaithambi G.
      • Castle A.L.
      • Sperl M.A.
      • Ravichandran J.
      • Gupta A.
      • Ho B.M.
      • et al.
      Thrombolytic treatment to stroke mimic patients via telestroke.
      Clin Neurol Neurosurg. 2017; 153: 5-7
      ,
      • Zerna C.
      • Yu A.Y.X.
      • Hong Z.M.
      • Penn A.M.
      • Lesperance M.L.
      • Croteau N.S.
      • et al.
      SpecTRA Study Group. White Matter Hyperintensity Volume Influences Symptoms in Patients Presenting With Minor Neurological Deficits.
      Stroke. 2020; 51: 409-415
      ].

      4.4 Thrombolysis

      20 studies reported thrombolysis rates between ischemic stroke and SM patients [
      • Garg R.
      • Rech M.A.
      • Schneck M.
      Stroke Mimics: An Important Source of Bias in Acute Ischemic Stroke Research.
      J Stroke Cerebrovasc Dis. 2019; 28: 2475-2480
      ,
      • Chtaou N.
      • Bouchal S.
      • Midaoui A.E.l.
      • Souirti Z.
      • Tachfouti N.
      • Belahsen M.F.
      Stroke Mimics: Experience of a Moroccan Stroke Unit.
      J Stroke Cerebrovasc Dis. 2020; 29: 104651https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104651
      ,
      • Ifergan H.
      • Amelot A.
      • Ismail M.
      • Gaudron M.
      • Cottier J.P.
      • Narata A.P.
      Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials.
      Arq Neuropsiquiatr. 2020; 78: 88-95
      ,
      • Uchino K.
      • Massaro L.
      • Hammer M.D.
      Transient ischemic attack after tissue plasminogen activator: aborted stroke or unnecessary stroke therapy?.
      Cerebrovasc Dis. 2010; 29: 57-61
      ,
      • Kostulas N.
      • Larsson M.
      • Kall T.-B.
      • von Euler M.
      • Nathanson D.
      Safety of thrombolysis in stroke mimics: an observational cohort study from an urban teaching hospital in Sweden.
      BMJ Open. 2017; 7: e016311https://doi.org/10.1136/bmjopen-2017-016311
      ,
      • Geisler F.
      • Ali S.F.
      • Ebinger M.
      • Kunz A.
      • Rozanski M.
      • Waldschmidt C.
      • et al.
      Evaluation of a score for the prehospital distinction between cerebrovascular disease and stroke mimic patients.
      Int J Stroke. 2019; 14: 400-408
      ,
      • Esmaeili S.
      • Afrakhteh M.
      • Bahadori M.
      • Shojaei S.F.
      • Ashayeri R.
      • Mehrpour M.
      Thrombolytic treatment in stroke mimic, inevitable but fortunately safe: An observational study from Iran.
      Iran J Neurol. 2019; 18: 172-175
      ,
      • Kvistad C.E.
      • Novotny V.
      • Næss H.
      • Hagberg G.
      • Ihle-Hansen H.
      • Waje-Andreassen U.
      • et al.
      Safety and predictors of stroke mimics in The Norwegian Tenecteplase Stroke Trial (NOR-TEST).
      Int J Stroke. 2019; 14: 508-516
      ,
      • Liberman A.L.
      • Liotta E.M.
      • Caprio F.Z.
      • Ruff I.
      • Maas M.B.
      • Bernstein R.A.
      • et al.
      Do efforts to decrease door-to-needle time risk increasing stroke mimic treatment rates?.
      Neurol Clin Pract. 2015; 5: 247-252
      ,
      • Avellaneda-Gómez C.
      • Rodríguez Campello A.
      • Giralt Steinhauer E.
      • Gómez González A.
      • Serra Martínez M.
      • de Ceballos C.P.
      • et al.
      Description of stroke mimics after complete neurovascular assessment.
      Neurologia. 2019; 34: 7-13
      ,
      • Siegler J.E.
      • Rosenberg J.
      • Cristancho D.
      • Olsen A.
      • Pulst-Korenberg J.
      • Raab L.
      • et al.
      Computed tomography perfusion in stroke mimics.
      Int J Stroke. 2020; 15: 299-307
      ,
      • Winkler D.T.
      • Fluri F.
      • Fuhr P.
      • Wetzel S.G.
      • Lyrer P.A.
      • Ruegg S.
      • et al.
      Thrombolysis in stroke mimics: frequency, clinical characteristics, and outcome.
      Stroke. 2009; 40: 1522-1525
      ,
      • Zinkstok S.M.
      • Engelter S.T.
      • Gensicke H.
      • Lyrer P.A.
      • Ringleb P.A.
      • Artto V.
      • et al.
      Safety of thrombolysis in stroke mimics: results from a multicenter cohort study.
      Stroke. 2013; 44: 1080-1084
      ,
      • Yaghi S.
      • Rayaz S.
      • Bianchi N.
      • Hall-Barrow J.C.
      • Hinduja A.
      Thrombolysis to stroke mimics in telestroke.
      J Telemed Telecare. 2012; https://doi.org/10.1258/jtt.2012.120510
      ,
      • Wilkins S.S.
      • Bourke P.
      • Salam A.
      • Akhtar N.
      • D'Souza A.
      • Kamran S.
      • et al.
      Functional Stroke Mimics: Incidence and Characteristics at a Primary Stroke Center in the Middle East.
      Psychosom Med. 2018; 80: 416-421
      ,
      • Hemmen T.M.
      • Meyer B.C.
      • McClean T.L.
      • Lyden P.D.
      Identification of nonischemic stroke mimics among 411 code strokes at the University of California, San Diego.
      Stroke Center. J Stroke Cerebrovasc Dis. 2008; 17: 23-25
      ,
      • Sharma R.
      • Macy S.
      • Richardson K.
      • Lokhnygina Y.
      • Laskowitz D.T.
      A blood-based biomarker panel to detect acute stroke.
      J Stroke Cerebrovasc Dis. 2014; 23: 910-918
      ,
      • Lewandowski C.
      • Mays-Wilson K.
      • Miller J.
      • Penstone P.
      • Miller D.J.
      • Bakoulas K.
      • et al.
      Safety and outcomes in stroke mimics after intravenous tissue plasminogen activator administration: a single-center experience.
      J Stroke Cerebrovasc Dis. 2015; 24: 48-52
      ,
      • Goyal N.
      • Male S.
      • Al Wafai A.
      • Bellamkonda S.
      • Zand R.
      Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment.
      J Stroke Cerebrovasc Dis. 2015; 24: 828-833
      ,
      • Sivakumaran P.
      • Gill D.
      • Mahir G.
      • Baheerathan A.
      • Kar A.
      A Retrospective Cohort Study on the Use of Intravenous Thrombolysis in Stroke Mimics.
      J Stroke Cerebrovasc Dis. 2016; 25: 1057-1061
      ]. 61.7% (10232/16586) of ischemic stroke patients were thrombolysed vs. 26.3% (635/2407) among SMs (p < 0.001). Three studies reported thrombectomy rates, 12.2% of ischemic stroke patients (140/1150) had revascularisation procedure, while no SM had thrombectomy (0/607) [
      • Chtaou N.
      • Bouchal S.
      • Midaoui A.E.l.
      • Souirti Z.
      • Tachfouti N.
      • Belahsen M.F.
      Stroke Mimics: Experience of a Moroccan Stroke Unit.
      J Stroke Cerebrovasc Dis. 2020; 29: 104651https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104651
      ,
      • Ifergan H.
      • Amelot A.
      • Ismail M.
      • Gaudron M.
      • Cottier J.P.
      • Narata A.P.
      Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials.
      Arq Neuropsiquiatr. 2020; 78: 88-95
      ,
      • Siegler J.E.
      • Rosenberg J.
      • Cristancho D.
      • Olsen A.
      • Pulst-Korenberg J.
      • Raab L.
      • et al.
      Computed tomography perfusion in stroke mimics.
      Int J Stroke. 2020; 15: 299-307
      ].
      Overall intracranial hemorrhage was reported in 9.4% of stroke (786/8403) vs. 0.7% in SM patients (4/524) (p < 0.001) [
      • Asaithambi G.
      • Castle A.L.
      • Sperl M.A.
      • Ravichandran J.
      • Gupta A.
      • Ho B.M.
      • et al.
      Thrombolytic treatment to stroke mimic patients via telestroke.
      Clin Neurol Neurosurg. 2017; 153: 5-7
      ,
      • Lewandowski C.
      • Mays-Wilson K.
      • Miller J.
      • Penstone P.
      • Miller D.J.
      • Bakoulas K.
      • et al.
      Safety and outcomes in stroke mimics after intravenous tissue plasminogen activator administration: a single-center experience.
      J Stroke Cerebrovasc Dis. 2015; 24: 48-52
      ,
      • Goyal N.
      • Male S.
      • Al Wafai A.
      • Bellamkonda S.
      • Zand R.
      Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment.
      J Stroke Cerebrovasc Dis. 2015; 24: 828-833
      ,
      • Garg R.
      • Rech M.A.
      • Schneck M.
      Stroke Mimics: An Important Source of Bias in Acute Ischemic Stroke Research.
      J Stroke Cerebrovasc Dis. 2019; 28: 2475-2480
      ,
      • Kostulas N.
      • Larsson M.
      • Kall T.-B.
      • von Euler M.
      • Nathanson D.
      Safety of thrombolysis in stroke mimics: an observational cohort study from an urban teaching hospital in Sweden.
      BMJ Open. 2017; 7: e016311https://doi.org/10.1136/bmjopen-2017-016311
      ,
      • Kvistad C.E.
      • Novotny V.
      • Næss H.
      • Hagberg G.
      • Ihle-Hansen H.
      • Waje-Andreassen U.
      • et al.
      Safety and predictors of stroke mimics in The Norwegian Tenecteplase Stroke Trial (NOR-TEST).
      Int J Stroke. 2019; 14: 508-516