Stroke Mimics

Record last-known-well time, characterize the deficit as negative versus positive, perform a focused neurologic examination, and obtain immediate glucose. Hypoglycemia can produce focal deficits, depressed consciousness, and seizures; rapidly correct a low glucose concentration while continuing the stroke evaluation if a focal deficit persists.AHA JournalsAHA JournalsGuidelines for the Early Management of Adults With ...

Obtain noncontrast head CT to exclude hemorrhage and, when an endovascular target is possible, CTA of the head and neck. A CT-based acute stroke protocol commonly includes noncontrast CT, CTA of brain and neck vessels, and CTP when available.PubMedPubMedStroke and Its Mimics: Diagnosis and Treatment - Diseases of the Brain, Head and Neck, Spine 2024-2027 - NCBI Bookshelf CTA/CTP findings must be interpreted against the examination: a normal CTA and CTP raise the probability of a mimic, but CTP can be normal in small lacunar infarction and can be nonspecific in mimics.PubMedPubMedStroke mimics: incidence, aetiology, clinical features and treatment

Send CBC with platelet count, electrolytes, renal function, PT/INR, and aPTT while imaging proceeds. Do not delay thrombolytic therapy awaiting routine results; prioritize platelet count and PT/INR when warfarin use or liver dysfunction makes them directly relevant to treatment eligibility.AHA JournalsAHA JournalsGuidelines for the Early Management of Adults With ...

Positive phenomena—witnessed convulsions, recurrent stereotyped sensory or motor events, visual aura, or spreading symptoms—favor seizure or migraine over an abrupt negative deficit. Ask specifically about seizure history, witnessed ictal activity, postictal confusion, prior similar migrainous episodes, aura preceding headache, and the sequence of symptom onset.AHA JournalsAHA JournalsGuidelines for the Early Management of Adults With ...

A deficit that does not conform to a vascular territory, lacks expected cranial nerve findings, or changes with distraction raises concern for functional neurologic disorder. Hoover sign is one of the few named bedside maneuvers identified as useful in the mimic differential; an internally inconsistent examination should trigger careful re-examination rather than premature diagnostic closure.AHA Journals+1AHA JournalsGuidelines for the Early Management of Adults With ...ScienceDirectIschemic stroke mimics: A comprehensive review

In acute vestibular presentations, use the HINTS examination only in the appropriate acute vestibular syndrome and only when performed by clinicians skilled in the maneuver. HINTS is among the limited clinical approaches identified in the literature as useful for distinguishing mimics, but posterior circulation ischemia remains an imaging-sensitive diagnostic problem.ScienceDirect+1ScienceDirectIschemic stroke mimics: A comprehensive reviewPubMedStroke mimics: incidence, aetiology, clinical features and treatment

Use MRI with DWI when CT/CTA/CTP is unrevealing or discordant with a persisting focal deficit, when symptoms are transient, or when a structural, inflammatory, neoplastic, venous, or seizure-related alternative remains plausible. MRI has greater sensitivity for early ischemic changes and is better than CT at identifying several infarct types and mimics, but longer acquisition time and safety screening can limit emergency use.PubMed+1PubMedStroke and Its Mimics: Diagnosis and Treatment - Diseases of the Brain, Head and Neck, Spine 2024-2027 - NCBI BookshelfPubMedStroke mimics: incidence, aetiology, clinical features and treatment

Do not interpret a negative MRI as absolute exclusion of stroke. Small infarctions, particularly brainstem lesions, may be missed on routine MRI; nevertheless, absent MRI lesions should increase concern for a mimic when imaging and clinical evolution remain incompatible with vascular ischemia.PubMedPubMedStroke mimics: incidence, aetiology, clinical features and treatment

In suspected seizure-related deficits, recognize that ictal hyperperfusion may be visible with arterial spin labeling, while seizure-related DWI hyperintensity with low ADC can resemble infarction. These seizure-associated MRI abnormalities are usually reversible, so correlate lesion distribution with clinical semiology, vascular imaging, and subsequent imaging rather than diagnosing ischemic stroke from DWI restriction alone.PubMedPubMedArterial Spin Labeling technique and clinical applications of the intracranial compartment in stroke and stroke mimics - A case-based review - PMC

Do not withhold IV thrombolysis solely because a common mimic is possible when the patient has a potentially disabling acute ischemic deficit and no contraindication. Current guideline language states that the very small risk of treating a stroke mimic is likely outweighed by the potential major benefit of IV thrombolysis in true ischemic stroke.AHA JournalsAHA Journals2026 Guideline for the Early Management of Patients With ...

If CTA identifies a thrombectomy-eligible occlusion, transfer or activate the endovascular pathway without waiting for MRI confirmation of infarction. Thrombectomy should be offered as soon as possible and within 6 hours of symptom onset for eligible acute ischemic stroke, with IV thrombolysis given when not contraindicated and within its applicable treatment window.nice org uknice org ukStroke and transient ischaemic attack in over 16s: ...

Once a mimic is established, treat the underlying process rather than labeling the presentation as a benign false alarm. Hypoglycemia requires prompt correction; suspected ongoing seizure requires electroclinical assessment; severe hypertension with encephalopathy and cerebral edema redirects care toward hypertensive encephalopathy/PRES evaluation; and structural, venous, neoplastic, or inflammatory imaging findings require cause-specific neurologic management.AHA Journals+2AHA JournalsGuidelines for the Early Management of Adults With ...PubMedStroke and Stroke Mimics: Diagnosis and Treatment - NCBIPubMedStroke and Its Mimics: Diagnosis and Treatment - Diseases of the Brain, Head and Neck, Spine 2024-2027 - NCBI Bookshelf

For a transient focal event without established mimic, complete urgent vascular assessment and etiologic evaluation rather than discharging on symptom resolution alone. CTA or MRA should be used to confirm stenosis greater than 50% after duplex screening, and laboratory evaluation should include vascular risk testing such as lipid panel, fasting glucose, and HbA1c.PubMedPubMedTransient Ischemic Attack - StatPearls - NCBI Bookshelf

For an established mimic, document the objective basis for diagnosis and arrange follow-up according to the cause: recurrent seizure-like events require neurology-directed evaluation, recurrent migrainous focal episodes warrant characterization of the stereotyped pattern, and functional presentations require a positive examination-based diagnosis rather than a diagnosis made only after exclusion. The initial workup should be revisited if recurrence deviates from the prior established pattern.AHA Journals+1AHA JournalsGuidelines for the Early Management of Adults With ...ScienceDirectIschemic stroke mimics: A comprehensive review