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Fortschr Neurol Psychiatr 2017; 85(12): 747-764
DOI: 10.1055/s-0043-111889
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Georg Thieme Verlag KG Stuttgart · New York

Stroke Mimics und Stroke Chamäleons – Differenzialdiagnose des Schlaganfalls

Stroke Mimics and Stroke Chameleons: Differential Diagnosis of Stroke
Frank Erbguth
Subject Editor: Prof. Dr. med. Frank Erbguth, Nürnberg
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Publication History

Publication Date:
06 December 2017 (online)

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Zusammenfassung

Durch die Einführung zeitkritischer Therapieoptionen beim ischämischen Schlaganfall und dem damit verbundenen Druck zum schnellen Handeln erhöht sich die Wahrscheinlichkeit von diagnostischen Fehleinschätzungen (Stroke Mimics und Stroke Chamäelons). Dieser Beitrag erklärt dieses Begriffspaar und seine Charakteristika in den unterschiedlichen Behandlungsphasen und zeigt die Möglichkeiten zur Reduzierung der Rate der Fehldiagnosen auf.

Abstract

The analysis of misdiagnosis of stroke has become increasingly relevant because of the time pressure in the thrombolytic treatment of ischemic strokes. Within the narrow time window of thrombolysis, a false-positive stroke diagnosis can lead to a faulty and potentially dangerous thrombolysis. The terms “Stroke Mimic” (SM = false-positive stroke diagnosis) and “Stroke Chameleon” (SC = false-negative stroke diagnosis) have been introduced for misdiagnosis in this field. The rate of SM decreases during the treatment phases from approximately 50 % in the preclinical situation to approximately 2–10 % in the Stroke Unit indicating thrombolytic therapy. The complication rate for not indicated thrombolysis in SM is low with 0.5 % for intracranial bleeding and 0.3 % for orolingual edema. Thus, the net balance in favour of fast thrombolysis is maintained, even when a higher number of mis-indicated lyses occurs in SM. The rate of SC during the stages of treatment drops from about 50 % in the preclinical stage to about 2–5 % in stroke units. The rates of SM and SC are inversely linked: a reduction in the SM rate leads to a more critical diagnosis of stroke, thus increasing the number of underdiagnosed stroke cases as SC, and vice versa. While SM rarely lead to the legal consequences of treatment error, SC often give rise to accusations of medical errors.

Schlüsselwörter

Stroke Mimics - Stroke Chamäleons - Schlaganfall-Fehldiagnosen - Schlaganfall-Differenzialdiagnosen

Key words

Stroke chameleons - stroke misdiagnosis - Stroke mimics - stroke differential diagnosis
 

  • Literatur

  • 1 Norris JW, Hachinski VC. Misdiagnosis of stroke. Lancet 1982; 1: 328-331
    PubMedGoogle Scholar
  • 2 Huff JS. Stroke mimics and chameleons. Emerg Med Clin North Am 2002; 20: 583-595
    CrossrefPubMedGoogle Scholar
  • 3 Fernandes PM, Whiteley WN, Hart SR. et al. Strokes: mimics and chameleons. Pract Neurol 2013; 13: 21-28
    CrossrefPubMedGoogle Scholar
  • 4 Liberman AL, Prabhakaran S. Stroke Chameleons and Stroke Mimics in the Emergency Department. Curr Neurol Neurosci Rep 2017; 17: 15
    CrossrefPubMedGoogle Scholar
  • 5 Lioutas VA, Sonni S, Caplan LR. Diagnosis and misdiagnosis of cerebrovascular disease. Curr Treat Options Cardiovasc Med 2013; 15: 276-287
    CrossrefPubMedGoogle Scholar
  • 6 Mead S, Rudge P. CJD mimics and chameleons. Pract Neurol 2017; 17: 113-121 doi:10.1136/practneurol-2016–001571
    CrossrefPubMedGoogle Scholar
  • 7 Webb J, Long B, Koyfman A. An Emergency Medicine-Focused Review of Seizure Mimics. J Emerg Med 2017; 52: 645-653 doi:10.1016/j.jemermed.2016.11.002
    CrossrefPubMedGoogle Scholar
  • 8 Weisberg LA, Nice CN. Intracranial tumors simulating the presentation of cerebrovascular syndromes. Am J Med 1977; 63: 517-524
    CrossrefPubMedGoogle Scholar
  • 9 Liberman AL, Liotta EM, Caprio FZ. et al. Do efforts to decrease door-to-needle time risk increasing stroke mimic treatment rates?. Neurol Clin Pract 2015; 5: 247-252
    CrossrefPubMedGoogle Scholar
  • 10 Burton TM, Luby M, Nadareishvili Z. et al. Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes. Neurology 2017; 89: 343-348
    CrossrefPubMedGoogle Scholar
  • 11 Guerrero WR, Savitz SI. Tissue-type plasminogen activator for stroke mimics: continuing to be swift rather than delaying treatment to be sure. Stroke 2013; 44: 1213-1214
    CrossrefPubMedGoogle Scholar
  • 12 Danière F, Edjlali-Goujon M, Mellerio C. et al. MR screening of candidates for thrombolysis: How to identify stroke mimics?. J Neuroradiol 2014; 41: 283-295
    CrossrefPubMedGoogle Scholar
  • 13 Nadarajan V, Perry RJ, Johnson J. et al. Transient ischaemic attacks: mimics and chameleons. Pract Neurol 2014; 14: 23-31
    CrossrefPubMedGoogle Scholar
  • 14 Amort M, Fluri F, Schäfer J. et al. Transient ischemic attack versus transient ischemic attack mimics: frequency, clinical characteristics and outcome. Cerebrovasc Dis 2011; 32: 57-64
    CrossrefPubMedGoogle Scholar
  • 15 Schulz UG, Rothwell PM. Transient ischaemic attacks mimicking focal motor seizures. Postgrad Med J 2002; 78: 246-247
    CrossrefPubMedGoogle Scholar
  • 16 Handschu R, Poppe R, Rauss J. et al. Emergency calls in acute stroke. Stroke 2003; 34: 1005-1009
    CrossrefPubMedGoogle Scholar
  • 17 Buck BH, Starkman S, Eckstein M. et al. Dispatcher recognition of stroke using the National Academy Medical Priority Dispatch System. Stroke 2009; 40: 2027-2030
    CrossrefPubMedGoogle Scholar
  • 18 Sequeira D, Martin-Gill C, Kesinger MR. et al. Characterizing Strokes and Stroke Mimics Transported by Helicopter Emergency Medical Services. Prehosp Emerg Care 2016; 20: 723-728
    CrossrefPubMedGoogle Scholar
  • 19 Ebinger M, Winter B, Wendt M. et al. STEMO Consortium. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. JAMA 2014; 311: 1622-1631
    CrossrefPubMedGoogle Scholar
  • 20 Itrat A, Taqui A, Cerejo R. et al. Telemedicine in Prehospital Stroke Evaluation and Thrombolysis: Taking Stroke Treatment to the Doorstep. JAMA Neurol 2016; 73: 162-168
    CrossrefPubMedGoogle Scholar
  • 21 Hemmen TM, Meyer BC, McClean TL. et al. 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
    CrossrefPubMedGoogle Scholar
  • 22 Hand PJ, Kwan J, Lindley RI. et al. Distinguishing between stroke and mimic at the bedside: the brain attack study. Stroke 2006; 37: 769-775
    CrossrefPubMedGoogle Scholar
  • 23 Dawson A, Cloud GC, Pereira AC. et al. Stroke mimic diagnoses presenting to a hyperacute stroke unit. Clin Med (Lond) 2016; 16: 423-426
    CrossrefPubMedGoogle Scholar
  • 24 Merino JG, Luby M, Benson RT. et al. Predictors of acute stroke mimics in 8187 patients referred to a stroke service. J Stroke Cerebrovasc Dis 2013; 22: e397-403
    CrossrefPubMedGoogle Scholar
  • 25 Brunser AM, Illanes S, Lavados PM. et al. Exclusion criteria for intravenous thrombolysis in stroke mimics: an observational study. J Stroke Cerebrovasc Dis 2013; 22: 1140-1145
    CrossrefPubMedGoogle Scholar
  • 26 Long B, Koyfman A. Clinical Mimics: An Emergency Medicine-Focused Review of Stroke Mimics. J Emerg Med 2017; 52: 176-183
    CrossrefPubMedGoogle Scholar
  • 27 Magauran Jr BG, Nitka M. Stroke mimics. Emerg Med Clin North Am 2012; 30: 795-804
    CrossrefPubMedGoogle Scholar
  • 28 Gibson LM, Whiteley W. The differential diagnosis of suspected stroke: a systematic review. J R Coll Physicians Edinb 2013; 43: 114-118
    CrossrefPubMedGoogle Scholar
  • 29 Quenardelle V, Lauer-Ober V, Zinchenko I. et al. Stroke Mimics in a Stroke Care Pathway Based on MRI Screening. Cerebrovasc Dis 2016; 42: 205-212
    CrossrefPubMedGoogle Scholar
  • 30 Gargalas S, Weeks R, Khan-Bourne N. et al. Incidence and outcome of functional stroke mimics admitted to a hyperacute stroke unit. J Neurol Neurosurg Psychiatry 2017; 88: 2-6
    CrossrefPubMedGoogle Scholar
  • 31 Scholten N, Pfaff H, Lehmann HC. et al. Thrombolyse des akuten Schlaganfalls – Eine deutschlandweite Analyse der regionalen Versorgung. Fortschr Neurol Psychiatr 2013; 81: 579-585
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Nguyen PL, Chang JJ. Stroke Mimics and Acute Stroke Evaluation: Clinical Differentiation and Complications after Intravenous Tissue Plasminogen Activator. J Emerg Med 2015; 49: 244-252
    CrossrefPubMedGoogle Scholar
  • 33 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: 115-120
    CrossrefPubMedGoogle Scholar
  • 34 Chen Y, Bogosavljevic V, Leys D. et al. Intravenous thrombolytic therapy in patients with stroke mimics: baseline characteristics and safety profile. Eur J Neurol 2011; 18: 1246-1250
    CrossrefPubMedGoogle Scholar
  • 35 Artto V, Putaala J, Strbian D. et al. Helsinki Stroke Thrombolysis Registry Group. Stroke mimics and intravenous thrombolysis. Ann Emerg Med 2012; 59: 27-32
    CrossrefPubMedGoogle Scholar
  • 36 Winkler DT, Fluri F, Fuhr P. et al. Thrombolysis in stroke mimics: frequency, clinical characteristics, and outcome. Stroke 2009; 40: 1522-1525
    CrossrefPubMedGoogle Scholar
  • 37 Sivakumaran P, Gill D, Mahir G. et al. A Retrospective Cohort Study on the Use of Intravenous Thrombolysis in Stroke Mimics. J Stroke Cerebrovasc Dis 2016; 25: 1057-1061
    CrossrefPubMedGoogle Scholar
  • 38 Chernyshev OY, Martin-Schild S, Albright KC. et al. Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology 2010; 74: 1340-1345
    CrossrefPubMedGoogle Scholar
  • 39 Lewandowski C, Mays-Wilson K, Miller J. 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
    CrossrefPubMedGoogle Scholar
  • 40 Tsivgoulis G, Alexandrov AV, Chang J. et al. Safety and outcomes of intravenous thrombolysis in stroke mimics: a 6-year, single-care center study and a pooled analysis of reported series. Stroke 2011; 42: 1771-1774
    CrossrefPubMedGoogle Scholar
  • 41 Zinkstok SM, Engelter ST, Gensicke H. et al. Safety of thrombolysis in stroke mimics: results from a multicenter cohort study. Stroke 2013; 44: 1080-1084
    CrossrefPubMedGoogle Scholar
  • 42 Tsivgoulis G, Zand R, Katsanos AH. et al. Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis. Stroke 2015; 46: 1281-1287
    CrossrefPubMedGoogle Scholar
  • 43 Goyal N, Male S, Al Wafai A. et al. Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment. J Stroke Cerebrovasc Dis 2015; 24: 828-833
    CrossrefPubMedGoogle Scholar
  • 44 Kuruvilla A, Bhattacharya P, Rajamani K. et al. Factors associated with misdiagnosis of acute stroke in young adults. J Stroke Cerebrovasc Dis 2011; 20: 523-527
    CrossrefPubMedGoogle Scholar
  • 45 Vroomen PC, Buddingh MK, Luijckx GJ. et al. The incidence of stroke mimics among stroke department admissions in relation to age group. J Stroke Cerebrovasc Dis 2008; 17: 418-422
    CrossrefPubMedGoogle Scholar
  • 46 Arch AE, Weisman DC, Coca S. et al. Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services. Stroke 2016; 47: 668-673
    CrossrefPubMedGoogle Scholar
  • 47 Lever NM, Nystrom KV, Schindler JL. et al. Missed opportunities for recognition of ischemic stroke in the emergency department. J Emerg Nurs 2013; 39: 434-439
    CrossrefPubMedGoogle Scholar
  • 48 Sarikaya H, Yilmaz M, Luft AR. et al. Different pattern of clinical deficits in stroke mimics treated with intravenous thrombolysis. Eur Neurol 2012; 68: 344-349
    CrossrefPubMedGoogle Scholar
  • 49 Madsen TE, Khoury J, Cadena R. et al. Potentially Missed Diagnosis of Ischemic Stroke in the Emergency Department in the Greater Cincinnati/Northern Kentucky Stroke Study. Acad Emerg Med 2016; 23: 1128-1135
    CrossrefPubMedGoogle Scholar
  • 50 Newman-Toker DE, Moy E, Valente E. et al. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis 2014; 1: 155-166
    CrossrefPubMedGoogle Scholar
  • 51 Richoz B, Hugli O, Dami F. et al. Acute stroke chameleons in a university hospital: Risk factors, circumstances, and outcomes. Neurology 2015; 85: 505-511
    CrossrefPubMedGoogle Scholar
  • 52 Dupre CM, Libman R, Dupre SI. et al. Stroke chameleons. J Stroke Cerebrovasc Dis 2014; 23: 374-378
    CrossrefPubMedGoogle Scholar
  • 53 Förster A, Griebe M, Wolf ME. et al. How to identify stroke mimics in patients eligible for intravenous thrombolysis?. J Neurol 2012; 259: 1347-1353
    CrossrefPubMedGoogle Scholar
  • 54 Segal J, Lam A, Dubrey SW. et al. Stroke mimic: an interesting case of repetitive conversion disorder. BMJ Case Rep. 2012 Nov 30; 2012. pii:bcr2012007556. doi:10.1136/bcr-2012–007556
    PubMedGoogle Scholar
  • 55 Aroor S, Singh R, Goldstein LB. BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of Strokes Missed Using the FAST Mnemonic. Stroke 2017; 48: 479-481
    CrossrefPubMedGoogle Scholar
  • 56 Moynihan B, Chowdhury R, Pereira A. FAST positive does not always mean stroke. Clin Med (Lond) 2010; 10: 194-195
    CrossrefPubMedGoogle Scholar
  • 57 Nor AM, Davis J, Sen B. et al. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet Neurol 2005; 4: 727-734
    CrossrefPubMedGoogle Scholar
  • 58 Brandler ES, Sharma M, Sinert RH. et al. Prehospital stroke scales in urban environments: a systematic review. Neurology 2014; 82: 2241-2249
    CrossrefPubMedGoogle Scholar
  • 59 Goyal N, Tsivgoulis G, Male S. et al. FABS: An Intuitive Tool for Screening of Stroke Mimics in the Emergency Department. Stroke 2016; 47: 2216-2220
    CrossrefPubMedGoogle Scholar
  • 60 Danière F, Edjlali-Goujon M, Mellerio C. et al. MR screening of candidates for thrombolysis: How to identify stroke mimics?. J Neuroradiol 2014; 41: 283-295
    CrossrefPubMedGoogle Scholar
  • 61 Goyal MS, Hoff BG, Williams J. et al. Streamlined Hyperacute Magnetic Resonance Imaging Protocol Identifies Tissue-Type Plasminogen Activator-Eligible Stroke Patients When Clinical Impression Is Stroke Mimic. Stroke 2016; 47: 1012-1017
    CrossrefPubMedGoogle Scholar
  • 62 Haferkamp G, Neu J, Wessel K. XXVIII-2: Behandlungsfehler in der Neurologie. In: Grisold W, Berlit P. Hrsg. Aktuelle Therapie in der Neurologie. 26. Erg.Lfg. 11/13. Heidelberg: ecomed Medizin; 1-20
    Google Scholar
  • 63 Vermeulen MJ, Schull MJ. Missed diagnosis of subarachnoid hemorrhage in the emergency department. Stroke 2007; 38: 1216-1221
    CrossrefPubMedGoogle Scholar
  • 64 Kowalski RG, Claassen J, Kreiter KT. et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA 2004; 291: 866-869
    CrossrefPubMedGoogle Scholar
  • 65 Inagawa T. Delayed diagnosis of aneurysmal subarachnoid hemorrhage in patients: a community-based study. J Neurosurg 2011; 115: 707-714
    CrossrefPubMedGoogle Scholar
  • 66 Yamada T, Natori Y. Evaluation of misdiagnosed cases of subarachnoid hemorrhage and causal factors for misdiagnosis. J Stroke Cerebrovasc Dis 2013; 22: 430-436
    CrossrefPubMedGoogle Scholar
  • 67 Edlow JA, Malek AM, Ogilvy CS. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. J Emerg Med 2008; 34: 237-251
    CrossrefPubMedGoogle Scholar
  • 68 Dubosh NM, Bellolio MF, Rabinstein AA. et al. Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Stroke 2016; 47: 750-755
    PubMedGoogle Scholar
  • 69 Karcz A, Holbrook J, Burke MC. et al. Massachusetts emergency medicine closed malpractice claims: 1988–1990. Ann Emerg Med 1993; 22: 553-559
    CrossrefPubMedGoogle Scholar
  • 70 Westwood AJ, Burns JD, Green DM. Teaching NeuroImages: pseudo-subarachnoid hemorrhage. Neurology 2012; 78: e54
    CrossrefPubMedGoogle Scholar
  • 71 Royl G, Ploner CJ, Leithner C. Dizziness in the emergency room: diagnoses and misdiagnoses. Eur Neurol 2011; 66: 256-263
    CrossrefPubMedGoogle Scholar
  • 72 Calic Z, Cappelen-Smith C, Anderson CS. et al. Cerebellar Infarction and Factors Associated with Delayed Presentation and Misdiagnosis. Cerebrovasc Dis 2016; 42: 476-484
    CrossrefPubMedGoogle Scholar