Clinical History Helps Distinguish TIA and Stroke From Mimics
In the posterior circulation, vascular syndromes involving the vertebrobasilar artery may manifest as ipsilateral cranial nerve deficits and ataxia involving the face, along with contralateral or bilateral sensory changes or weakness of the body. The classic indicators of vertebrobasilar artery involvement are diplopia, dysarthria, disequilibrium, drowsiness, and death. Vascular syndromes involving the posterior cerebral artery characteristically involve a contralateral visual field deficit.
Psychiatric Conditions May Also Mimic Stroke
While partial seizures and complicated migraine are the most common and important mimics of TIA or stroke, panic attacks, conversion disorder, vertigo, and syncope occasionally can be confused with TIA.
Panic attacks occasionally involve focal neurologic symptoms, but the symptoms are more typically vague and random. “It’s ‘I got numb and tingly all over,’ rather than ‘I got numb and tingly on one-half of my body,’” said Dr. Hickenbottom.
Affected patients generally have a history of panic disorder or an anxiety disorder, and symptoms that suggest a neurologic condition are accompanied by other panic symptoms, including shortness of breath, dizziness, palpitation, abdominal pain, or fear of dying.
Patients with conversion disorder–related symptoms that appear to be neurologic most often have a history of psychiatric disease of some other kind. On careful examination, their seemingly neurologic symptoms do not adhere to a physiologic pattern. Examination may reveal inconsistencies such as nonphysiologic sensory loss or weakness or absence of tremor when the patient is distracted by a task. The distinctions can be subtle; a neurologic consultation can be helpful when conversion disorder is suspected.
Isolated vertigo with no other accompanying neurologic symptoms is seldom vascular in nature. “The brainstem is so small that to have a vascular episode that just affects the vestibular nuclei without causing double vision, slurred speech, a droopy face, or something else is pretty unlikely,” Dr. Hickenbottom said.
Syncope is a diffuse and acute process rather than the focal, acute process that defines TIA and stroke. Neurologists see many patients with syncope, but syncope rarely has a neurologic cause. It may have such a cause, however, when a patient experiences several minutes of confusion after waking up from a syncopal episode. Patients typically return to their normal mental status rapidly. Prolonged confusion raises the possibility of a seizure disorder with postictal confusion, said Dr. Hickenbottom.
—Bruce Jancin
IMNG Medical News
Suggested Reading
Artto V, Putaala J, Strbian D, et al. Stroke mimics and intravenous thrombolysis. Ann Emerg Med. 2012; 59(1):27-32.
Brunser AM, Illanes S, Lavados PM, et al. Exclusion criteria for intravenous thrombolysis in stroke mimics: an observational study. J Stroke Cerebrovasc Dis. 2012 Dec 14. pii: S1052-3057(12)00363-1 [Epub ahead of print].
Eichel R, Hur TB, Gomori JM, et al. Use of DWI-only MR protocol for screening stroke mimics. J Neurol Sci. 2013;328(1-2):37-40.
Guillan M, Alonso-Canovas A, Gonzalez-Valcarcel J, et al. Stroke mimics treated with thrombolysis: further evidence on safety and distinctive clinical features. Cerebrovasc Dis. 2012;34(2):115-120.
Zinkstok SM, Engelter ST, Gensicke H, et al. Safety of thrombolysis in stroke mimics: results from a multicenter cohort study. Stroke. 2013;44(4):1080-1084.
