Frequency and Characteristics of Non-Neurological and Neurological Stroke Mimics in the Emergency Department

Jordi Kühne Escolà; Bessime Bozkurt; Bastian Brune; Woon Hyung Chae; Lennart Steffen Milles; Doreen Pommeranz; Lena Brune; Philipp Dammann; Ulrich Sure; Cornelius Deuschl; Michael Forsting; Clemens Kill; Christoph Kleinschnitz; Martin Köhrmann; Benedikt Frank

doi:10.3390/jcm12227067

Frequency and Characteristics of Non-Neurological and Neurological Stroke Mimics in the Emergency Department

J Clin Med. 2023 Nov 13;12(22):7067. doi: 10.3390/jcm12227067.

Authors

Jordi Kühne Escolà¹, Bessime Bozkurt¹, Bastian Brune^{2

3}, Woon Hyung Chae¹, Lennart Steffen Milles¹, Doreen Pommeranz¹, Lena Brune¹, Philipp Dammann⁴, Ulrich Sure⁴, Cornelius Deuschl⁵, Michael Forsting⁵, Clemens Kill⁶, Christoph Kleinschnitz¹, Martin Köhrmann¹, Benedikt Frank¹

Affiliations

¹ Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, 45147 Essen, Germany.
² Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, 45147 Essen, Germany.
³ Medical Emergency Service of the City of Essen, 45139 Essen, Germany.
⁴ Department of Neurosurgery and Spine Surgery, University Hospital Essen, 45147 Essen, Germany.
⁵ Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, 45147 Essen, Germany.
⁶ Center of Emergency Medicine, University Hospital Essen, 45147 Essen, Germany.

Abstract

Background: Stroke mimics are common in the emergency department (ED) and early detection is important to initiate appropriate treatment and withhold unnecessary procedures. We aimed to compare the frequency, clinical characteristics and predictors of non-neurological and neurological stroke mimics transferred to our ED for suspected stroke.

Methods: This was a cross-sectional study of consecutive patients with suspected stroke transported to the ED of the University Hospital Essen between January 2017 and December 2021 by the city's Emergency Medical Service. We investigated patient characteristics, preclinical data, symptoms and final diagnoses in patients with non-neurological and neurological stroke mimics. Multinominal logistic regression analysis was performed to assess predictors of both etiologic groups.

Results: Of 2167 patients with suspected stroke, 762 (35.2%) were diagnosed with a stroke mimic. Etiology was non-neurological in 369 (48.4%) and neurological in 393 (51.6%) cases. The most common diagnoses were seizures (23.2%) and infections (14.7%). Patients with non-neurological mimics were older (78.0 vs. 72.0 y, p < 0.001) and more likely to have chronic kidney disease (17.3% vs. 9.2%, p < 0.001) or heart failure (12.5% vs. 7.1%, p = 0.014). Prevalence of malignancy (8.7% vs. 13.7%, p = 0.031) and focal symptoms (38.8 vs. 57.3%, p < 0.001) was lower in this group. More than two-fifths required hospitalization (39.3 vs. 47.1%, p = 0.034). Adjusted multinominal logistic regression revealed chronic kidney and liver disease as independent positive predictors of stroke mimics regardless of etiology, while atrial fibrillation and hypertension were negative predictors in both groups. Prehospital vital signs were independently associated with non-neurological stroke mimics only, while age was exclusively associated with neurological mimics.

Conclusions: Up to half of stroke mimics in the neurological ED are of non-neurological origin. Preclinical identification is challenging and a high proportion requires hospitalization. Awareness of underlying etiologies and differences in clinical characteristics is important to provide optimal care.

Keywords: non-neurological; prehospital; stroke diagnosis; stroke mimics; suspected stroke.

Grants and funding

We acknowledge support by the Open Access Publication Fund of the University of Duisburg-Essen.