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Can Headache Help to Rule out Stroke Mimics during Stroke Alert?

Evgeny V Sidorov, David M. Thompson, Vijay Pandav, Joshua Santucci, Bradley Bohnstedt and Bappaditya Ray

Objective: When patients present to the emergency department (ED) with acute focal neurological deficit, sometimes it is hard to make a decision about IV thrombolysis. In such situations, neurologists need to make a judgment call about it. According to some studies, IV thrombolysis is safe for patients with stroke mimics; however, a small possibility of hemorrhage still exists. Furthermore, unnecessary IV thrombolysis in stroke mimics significantly increases cost of care. We aimed to determine if presence of headache in patients with focal neurological deficit during stroke alerts makes a difference in the neurologist decision about IV thrombolysis.
Methods: A retrospective chart review of 326 patients who presented to The University of Oklahoma Medical Center (OUMC) as a stroke alert in 2013.
Results: At OUMC, 151 patients were ineligible for IV thrombolysis. Out of the remaining 175 patients, 62 presented with and 113 without headache. Seven out of the 62 patients with headache were initially diagnosed in the ED with ischemic stroke and received IV thrombolysis. On later evaluation, all of these 62 patients turned out to be stroke mimics. Forty-five out of 113 patients without headache were initially diagnosed as ischemic stroke in the ED and received IV thrombolysis. Nine of these 45 patients were later diagnosed as stroke mimics while 36 had ischemic stroke. Out of the remaining 68 patients without headache, who were initially diagnosed with stroke mimics and did not receive IV thrombolysis, 4 were later diagnosed with ischemic stroke and 64 were confirmed stroke mimics. In general, patients with headache had much less frequent IV thrombolysis 7/62 (11%) than patients without headache 45/113 (40%) (p<0.0001). No patients with headache, compared to 40 patients (36 who had IV thrombolysis+4 who did not) without headache, were later diagnosed with ischemic stroke (p<0.0001).
Conclusion: Patients with headache and acute focal neurological deficit less frequently receive IV thrombolysis and are less frequently diagnosed with ischemic stroke after completion of workup. Presence of headache may help neurologists to decide whether to do IV thrombolysis.