Published Online
on February 16, 2006

A more recent version of this article appeared on March 1, 2006

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Submitted on November 13, 2005
Revised on December 18, 2005
Accepted on January 1, 2006

Distinguishing Between Stroke and Mimic at the Bedside. The Brain Attack Study

Peter J. Hand MD, FRACP^*; Joseph Kwan MD, MRCP; Richard I. Lindley MD, FRACP; Martin S. Dennis MD, FRCP; and Joanna M. Wardlaw MD, FRCP, FRCR

From the Division of Clinical Neurosciences (M.S.D., J.M.W.), Western General Hospital, Edinburgh, UK; RMH Stroke Centre (P.J.H.), Department of Neurology, Royal Melbourne Hospital, and Department of Medicine (Neuroscience), Monash University (Alfred Hospital Campus), Victoria, Australia; University Department of Geriatric Medicine (J.K.), Level E (MP807), Southampton General Hospital, Southampton, UK; and Department of Geriatric Medicine (R.I.L.), Western Clinical School, University of Sydney, Westmead Hospital, New South Wales, Australia.

^* To whom correspondence should be addressed. E-mail: peter.hand{at}mh.org.au.

Background and Purpose--The bedside clinical assessment of the patient with suspected stroke has not been well studied. Improving clinical skills may accelerate patient progress through the emergency department. We aimed to determine the frequency and nature of stroke mimics and to identify the key clinical features that distinguish between stroke and mimic at the bedside.

Methods--Consecutive presentations to an urban teaching hospital with suspected stroke were recruited. A standard bedside clinical assessment was performed. The final diagnosis was determined by an expert panel, which had access to clinical features, brain imaging, and other tests. Univariate and multivariate analyses determined the bedside features that distinguished stroke from mimic.

Results--There were 350 presentations by 336 patients. The final diagnosis was stroke in 241 of 350 (69%) and mimic in 109 (31%). The mimics included 44 events labeled "possible stroke or TIA." Eight items independently predicted the diagnosis in patients presenting with brain attack: cognitive impairment and abnormal signs in other systems suggested a mimic, an exact time of onset, definite focal symptoms, abnormal vascular findings, presence of neurological signs, being able to lateralize the signs to the left or right side of the brain, and being able to determine a clinical stroke subclassification suggested a stroke.

Conclusions--The bedside clinical assessment can be streamlined substantially. This has important implications for teaching less experienced clinicians how to assess the patient with suspected stroke.

Key words: diagnosis • stroke, acute • stroke assessment

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