Here are 5 points about stroke mimickers in the emergency department. IV tissue plasminogen activator (tPA) is given in 15% of stroke mimics. 

​

1. Migraine with Aura:  A stroke is a sudden onset vascular emergency. Migraine symptoms typically follow a "spreading" pattern. Aura develops over <20 minutes and lasts <60 minutes. Migraines present with positive phenomena (scintillating scotomas, tingling, or "pins and needles"), whereas strokes present with negative phenomena (visual field loss, numbness, or "dead weight" weakness).

​

2. Post-ictal/Seizures: Seizures can present as focal motor activity or as a post-ictal focal deficit (Todd’s paralysis). 

​

3. Metabolic: Check for hypoglycemia. Hyponatremia or encephalopathy (hepatic encephalopathy, encephalitis) present with more global features or "wavering" deficits. Strokes are focal to a vascular territory. Consider infectious causes, particularly in elderly patients.  

​

4. Cardiac and other mimics: Think about aortic dissection and cardiac causes of syncope in the stroke differential. Drugs (alcohol, other intoxication), peripheral neuropathies, transient global amnesia and functional disorders account for other mimickers.  

​

5. Stroke mimics are more common in:

Patients < 50 years.

Patients with a history of cognitive impairment, migraines, or seizures.

Absence of hypertension, diabetes, hyperlipidemia, atrial fibrillation.