# The Incidence of Stroke Mimics in the Emergency Department of a Tertiary-care Center in Lebanon

## TL;DR

This study finds that nearly half of patients presenting with stroke-like symptoms in a Lebanese hospital are not having a real stroke, highlighting the need for better triage methods.

## Contribution

The study provides a detailed analysis of stroke mimic incidence and etiologies in a Lebanese tertiary-care center, identifying key risk factors.

## Key findings

- 40.2% of stroke code activations were for stroke mimics rather than true strokes.
- Medical etiologies accounted for 87.2% of stroke mimics, with neurological causes being the most common.
- Neurological or psychiatric history and altered mental status increased the likelihood of stroke mimics.

## Abstract

Stroke mimics comprise a significant proportion of cases presenting with neurological deficits and can be difficult to differentiate from true stroke cases. Our aim in this study was to assess the frequency and etiologies of stroke mimics presenting to our emergency department (ED).

We conducted a retrospective review of the charts of patients presenting to the ED of a tertiary-care center between November 2018–August 2023 and on whom the stroke code was activated. The cases were categorized into real strokes or stroke mimics based on patients’ discharge diagnoses.

Stroke code activation was implemented on 584 patients during the study period. These patients received full service and a final discharge diagnosis. Of these, 349 (59.8%) received a diagnosis of a true stroke, whether ischemic, hemorrhagic, or transient ischemic attack. The remaining 235 (40.2%) were classified as stroke mimics, with functional (12.8%) and medical (87.2%) etiologies. Medical stroke mimics were further categorized into non-cerebrovascular neurologic (59.5%), infection or allergic reaction (17.1%), cardiovascular (11.7%), metabolic or drug-induced (8.3%), and other (3.4%). Factors found to favor stroke mimics were history of neurological (adjusted odds ratio [aOR] 4.98; 95% confidence interval [CI] 2.89 – 8.57) or psychiatric disorders (aOR 2.88; 95% CI 1.29 – 6.41) and patients presenting with altered mental status (aOR 1.70; 95% CI 1.04 – 2.80) or generalized weakness (aOR 2.38; 95% CI1.12 – 5.03). Conversely, factors that favored true strokes (with OR <1 for mimics), were patients aged >65 years (aOR 0.61; 95% CI 0.38–0.96), history of hypertension (aOR 0.61; 95% CI 0.38 – 0.97) or atrial fibrillation (aOR 0.39; 95% CI 0.21 – 0.72), and presenting with speech disturbance (aOR 0.56; 95% CI 0.37–0.83) or extremity weakness (aOR: 0.22; 95% CI 0.15–0.38).

Approximately 40% of cases presenting to our ED with stroke code activation were found to be mimics. The high ratio warrants the establishment and adoption of a more specific triaging algorithm for stroke code activation to minimize the pressure on an already overburdened healthcare sector.