Challenges in Diagnosis of Ischaemic Stroke: A Descriptive Study of Stroke Mimics and Missed Strokes

Background: Despite technologic advances, stroke remains a difficult clinical diagnosis. We aimed to investigate the rate and characteristics of stroke mimics (SM) and missed strokes (MS). Research Methodology: We used data of consecutive “suspected stroke” admissions in a tertiary academic Hospital from January 2016 to July 2018. Diagnosis of SM was based on the absence of an ischaemic infarct on neuroimaging plus the presence an alternate discharge diagnosis. MS were defined as any patient with a discharge diagnosis of stroke whose stroke-like symptoms were missed in the Emergency Department (ED). Findings: Of 1745 patients reviewed, 63% were ischaemic stroke, 18% Intra-Cranial Haemorrhage (ICH), and 18% SM. We detected 95 MS. Stroke risk factors were significantly less common among SM and MS compared to stroke patients. Younger age, female gender, dizziness, ataxia, absence of limb weakness, and absence of certain vascular risk factors were predictors of SM. For MS, the predicting factors were young age (<55), confusion at presentation, hypercholesterolemia, and absence of hypertension. Conclusion: Atypical presenting symptoms can cause over and under-diagnosis of stroke. MS and SM are similar in many aspects. These diagnostic errors occur more often in younger patients with less severe neurological symptoms and symptoms attributable to posterior circulation.