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(speech and comprehension communication disorders), altered mental status, seizures and headaches have been shown to be misdiagnosed by
paramedics 27% of the time.(2)
Stroke mimics have been shown to be misdiagnosed by physicians in the hospital setting 31% of the time.(2) A prehospital assessment or field
diagnosis of stroke is typically derived from the patient history, the physical examination and clinical tests, such as blood glucose level and
neurologic tests (right- and left-side strength and compliance).(5) A key differential to distinguish strokes from those disorders that mimic a
stroke include the rapidity of onset, which tends to occur with strokes and not with most other mimics.
A mnemonic to help keep stroke mimics in mind is HEMI: hypoglycemia (and hyperglycemia), epilepsy, multiple sclerosis (and hemiplegic
migraine) and intracranial tumors (or infections, such as meningitis, encephalitis and abscesses).(6) Most errors in the misdiagnosis of stroke
occur when patients cant provide a past medical history due to impaired speech or altered mental status, or if their past medical history is
unreliable (e.g., in the presence of strangers who are unfamiliar with the patients past medical history). (See Table 1, pg 80, JEMS March 2011.)
Here, we present four case scenarios in which the patient appears to have had a stroke, but in fact has one of four stroke mimics: hypoglycemia,
hyperglycemia, migraine or seizure.
Hypoglycemia: Case Presentation #1
Mrs. Jackson calls EMS because she woke up in the morning to find her 35-year-old husband lying in bed confused, exhibiting a left-side facial
droop and not moving his left arm and leg. EMS arrived and see the patient lying in bed confused with slurred speech, left-side facial droop and
left side-paralysis. They administer oxygen (O2) via non-rebreather mask at 12 L/min and start an IV of normal saline TKO and transported to
the stroke center on the ECG monitor. En route, the crew checks his blood glucose serum level; its 35 mg/dL. They administer an amp (50 cc's)
of dextrose 50% D50 in water, and the symptoms cleared. At the hospital, the emergency department (ED) physician consults with the neurology
department, and an MRI is performed and found to be negative for stroke.
Hypoglycemia is the most easily detected stroke mimic, because a blood glucose level test is usually reliable and indicates the presence of low
blood sugar. Patients typically respond rapidly to the administration of a bolus of D50. Although hypoglycemia sometimes presents with
hemiplegia and aphasia, hypoglycemic patients who present with these signs will most often be alert and not also concurrently show the more
severe signs of confusion and altered mental status or coma.(7)
Hypoglycemia most often goes undetected as a stroke mimic when the field
provider becomes so convinced by the presenting signs and symptoms that the patient is having as stroke that they fail to follow the standard
altered mental status protocol and perform the blood glucose level test.
Hyperglycemia: Case Presentation #2
EMS responds to Mrs. Reynolds, a 50-year-old female with a history of hepatic encephalopathy and end-stage liver disease. Her husband called
9-1-1 because she suddenly began to have jerking movements of her upper left arm and hand. EMS providers check her blood glucose serum
level, which reads high. They transport her to the ED on O2 and start an IV of normal saline solution en route.
Mrs. Reynolds has intermittent choreo-athetotic movements of her left upper extremities en route. On further examination, there was dysmetria
of the left upper extremities and left lower extremities. Her Cincinnati Prehospital Stroke Scale level was 3, and the stroke team at the hospital
was activated. A screening MRI rules out stroke. Her blood glucose level came back at 1245 mg/dL. Symptoms were resolved with treatment for
hyperglycemia.
Hyperglycemia is most often confused with stroke when it presents with a generalized, global, altered mental status or coma. The lack of a past
medical history indicating a long and gradual onset combined with a nonspecific high blood glucose level reading leads to a reasonable
suspicion of stroke. Assessing the patient with a standardized assessment instrument, such as the Cincinnati Prehospital Stroke Scale is one of
the best ways to increase the specificity of assessment for strokes.(2) (See Table 2, pg. 81)
Hemiplegic Migraine: Case Presentation #3
Helen Bradshaw, a 50-year-old female in generally good health suddenly developed paralysis of her upper extremities. Her husband calls 9-1-1,
and the EMS crew arrives in seven minutes. They find her lying in bed with bilateral paralysis of her arms and hands. As the paramedics delve
deeper with their assessment questions about her medical history, they learn from her husband that shes had intermittent headaches for most of
her life but has never seen a doctor for them.
As they continue to ask pertinent questions to explore any associated symptoms about her headaches, she states that she noticed squiggly lines
in her visual fields and says it was just after she noticed those that she developed the weakness. As she relates this history, she reports that she
was having one of her throbbing, generalized headaches. As the paramedics gather the curious history, signs and symptoms, her weakness begins
to resolve, and her headache begins to throb with greater intensity. The ED physician treats Mrs. Bradshaw for her migraine headache, and the
symptoms completely resolve.
Familial hemiplegic migraine (FHM) is a rare variant of migraine with an aura. Symptoms include hemiparesis, visual disturbances (aura) and
dysphasia. Set criteria exist to establish the diagnosis, but diagnosis at the first attack may be impossible.8 Clues to this disorder are a family
history of migraines, in particular FHM and a typical throbbing headache with an aura. Stroke may present with headache, but a prominent
headache suggests a diagnosis other than ischemic stroke. Hypertensive intracerebral hemorrhage, subarachnoid hemorrhage and FHM may all
present with headache and hemiparesis.
Epilepsy (Todds Paralysis): Case Presentation #4
Ralph Morris, a 47-year-old male, planned to go fishing at 5 a.m. with his son, Larry. But when Larry tried to wake up Ralph, he found that his
dad was confused and couldnt move his left arm and leg. Larry calls 9-1-1, and EMS arrives in 12 minutes. The crew starts O2 via nonrebreather mask at 12 L/min. and an IV of normal saline TKO and places ECG leads.
They find Ralph confused, with slurred speech and left-side paralysis, and are certain he had a stroke. As the paramedics continue to ask Larry
about what happened prior to their arrival, he mentions his dads left hand had been jerking a little when he first went in to wake him up. Larry
also mentions hed noticed that his dads eyes were slanted to the left and he had drooled a little, as well. The paramedics transport Ralph
expeditiously to the closest ED for treatment for a possible stroke.
A routine blood glucose level test in the ED shows 50 mg/dL, and 25 g of D50W is administered. The IV is switched to D10W. Ralph responds
quickly to the glucose and can answer questions. He lets them know that he has a past history of epilepsy and hasnt been taking his medications
recently. He also lets them know hed experienced an episode of hemiparesis in the past following one of his seizures. The ED physician has the
nursing staff explain to Ralph the importance of compliance when taking anti-seizure medications, and hes discharged with no further ED
treatment needed.
Robert Bentley Todd (18091860) was an anatomist, pathologist and physiologist and the first person to present an electrical theory of epilepsy.
He stated, in 1849, that some patients who recover from a severe fit, or from frequently repeated fits of epilepsy, are often found to labor under
hemiplegia, or other modifications of palsy.
Multiple neurologists subsequently described the same phenomena.(9) The patient presents with a hemiparesis and possibly aphasia after having
had a seizure of variable duration. The stroke-like symptoms resolve after a variable amount of time, ranging from a few minutes to several
weeks.(10) The key to diagnosis is the history of a seizure or seizures. A clue on physical exam is a bite mark on the lateral side of the tongue,
which may be seen in up to 64% of patients who die during a seizure. Another clue to a possible seizure is the presence of a postictal state (i.e.,