Neurology Asia 2021; 26(1) : 35 – 39

Profile of stroke mimics in a tertiary medical center

in the Philippines
Ferron F. Ocampo MD, Francesca Rose G. De Leon-Gacrama MD, Joven R. Cuanang
MD, Jose C. Navarro MD

Institute for Neurosciences, St. Luke’s Medical Center, Quezon City, Philippines

Abstract

Background & Objectives: Stroke mimics are conditions that simulate the signs and symptoms of a
stroke. These conditions pose a clinical challenge as they need to be distinguished from actual strokes
based on neurologic findings, laboratory tests, and imaging studies in order to minimize the adverse
effects of acute stroke therapies as well as hospital costs. The study aims to determine the rate and
the most common etiologies of stroke mimics in a private tertiary care hospital in the Philippines and
calculate the average cost incurred for diagnostics. Methods: We conducted a retrospective review of
medical records of adult patients assessed by the hospital’s Brain Attack Team from 1 January 2014
to 31 December 2017. The diagnosis of stroke mimic was based on negative neuroimaging findings
and laboratory results that showed an alternate diagnosis, in consultation with the stroke neurologist
on call. Results: A total of 1,485 patient records were analyzed; 448 patients (30.2%) were diagnosed
as stroke mimics. The most common etiologies were encephalopathy (83 cases, 18.5%), seizures (77
cases, 17.2%), headache (31 cases, 6.9%), hypertensive emergency (31 cases, 6.9%), and radiculopathy
(27 cases, 6.0%). The average cost for diagnostics for each patient diagnosed as a stroke mimic was
PHP 24,629.53 (approximately US$500).
Conclusion: Stroke mimics are often encountered in the emergency setting. Due to the wide range of
medical conditions that mimic stroke, early recognition is important in order to avoid the potential
adverse effects of acute stroke therapies and minimize diagnostic costs, particularly in countries with
limited resources.

Keywords: Stroke mimics, stroke, brain attack, diagnostic costs, cost burden

INTRODUCTION mimics among healthcare institutions. Moreover,

published costing studies on the estimated total
In the Philippines, cerebrovascular disease is the
and mean diagnostic costs incurred by patients
second leading cause of mortality, with an overall
who presented with stroke mimics are lacking.
prevalence of 0.9%.1 Rapid and accurate diagnosis
Our study aims to determine the frequency and
of stroke is critical, particularly in patients who
most common etiologies of stroke mimics in
are eligible for intravenous thrombolysis or
our hospital and calculate the average costs for
mechanical thrombectomy. A stroke mimic is a
diagnostic tests for these patients.
condition that manifests with a stroke-like clinical
picture due to symptoms caused by a disease
other than cerebrovascular disorders.2 In various METHODS
studies, the most common medical conditions
that mimic stroke include seizure, syncope, Patient selection and study site
encephalopathy, primary headache disorders, We conducted a retrospective review of hospital’s
space-occupying lesions, functional disorders, and medical records and stroke database. All adult
metabolic imbalances.3 The incidence of stroke patients (age > 18 years old), who presented with
mimics across different hospitals worldwide signs and symptoms of stroke (focal neurological
ranged from 1% to 30%.4-8 However, in the symptoms with sudden onset) in the emergency
Philippines, there are no published data on the room, medical wards or the intensive care units,
incidence and most common etiologies of stroke and were assessed by the hospital’s Brain Attack
Address correspondence to: Ferron F. Ocampo, M.D., Institute for Neurosciences, St. Luke’s Medical Center, E. Rodriguez Sr. Avenue, Quezon City, 1114
Philippines. Tel: (+63)-917-891-8373, (+63)-943-554-9561, Email: [email protected]
Date of Submission: 4 August 2020; Date of Acceptance: 5 October 2020

35
Neurology Asia March 2021

Team (BAT) from January 1, 2014 to December to determine the incidence rate, most common
31, 2017 were included in the study. etiologies of stroke mimics, total diagnostic costs
The study site is at St. Luke’s Medical Center and average costs of diagnostics per patient.
(Quezon City, Philippines), a 650-bed tertiary
hospital accredited by the Joint Commission RESULTS
International (JCI) as a Primary Stroke Center.
A total of 1,485 patients were seen by the Brain
It is equipped with all the necessary laboratory, Attack Team, both in the emergency department
neuroradiological, and neurosurgical facilities, as and in-hospital, over the four-year period. Among
well as critical care units capable of managing these, 448 patients (30.17%) were diagnosed as
acute stroke patients. The hospital’s Brain Attack stroke mimics, with mean age of 59.4 years (SD
Team is composed of stroke neurologists, stroke 16.5) and majority (54%) were females (Table 1).
fellow, neurology residents, nursing associates, Among the 448 patients, 317 (79%) were initially
and paramedical staff. When a Brain Attack assessed in the emergency department while 131
code is activated within the hospital, the team (21%) were already admitted for another medical
proceeds to assess the patient at bedside, obtain condition in the medical wards and in the intensive
the pertinent neurologic history, and perform a care units (ICUs). The proportion of stroke mimics
complete neurologic examination to determine among inpatients was higher compared to those
whether the symptoms are consistent with a seen in the emergency department (55.5% vs.
possible cerebrovascular event and if the patient 25.4%) (Table 2).
is a candidate for acute stroke interventions The most common etiologies of stroke mimics
such as intravenous thrombolysis or mechanical are: (1) encephalopathy (n=83, 18.5%), which
thrombectomy. The case is discussed with the comprise of septic, metabolic, uremic, and hepatic
stroke neurologist on-call and subsequently, the encephalopathy; (2) seizures, focal or generalized
appropriate neuroimaging modality and laboratory (n=77, 12.2%); (3) headache (n=31, 6.9%); (4)
tests are requested. A diagnosis of stroke mimic hypertensive emergency (n=31, 6.9%), and; (5)
was determined after neuroimaging studies did not radiculopathies (n=27, 6.0%) (Table 3). In the
emergency department, seizures, encephalopathy,
show radiographic findings consistent with stroke
and headache are the most common conditions
and laboratory test results showed an alternate
mimicking stroke (Table 4). Among inpatients,
diagnosis other than stroke, in consensus with
encephalopathy, seizures, sepsis, and syncope
the stroke neurologist assigned to the patient. are the most common stroke mimics (Table 5).
The total costs of diagnostics (comprising of
Data Collection and analysis laboratory tests and imaging studies) for patients
The following data were retrieved from the diagnosed as stroke mimics were calculated to be
patient’s clinical records: hospital patient PHP 11,034,031.58 (USD 220,680.63) or roughly
identification number, age, sex, date and time of PHP 24,629.53 (USD 492.59) for each patient
ictus, time of brain attack code activation, initial (Table 6).
diagnosis, laboratory test results, imaging results,
final diagnosis, etiology of stroke mimic, and final DISCUSSION
disposition (admission or discharge). The costs Over the four-year study period, there were 1,485
for the laboratory tests and imaging procedure for patients assessed by the hospital’s Brain Attack
each patient was calculated using the price of each Team and 448 were eventually diagnosed as
laboratory test or imaging modality during the stroke mimics (30.2%). The incidence rate of
four-year period. Descriptive statistics were used stroke mimic in our hospital is consistent with

Table 1: Baseline characteristics of patients diagnosed as stroke mimics from 2014-2017

Brain Attack Codes 1,485
Stroke mimics 448
Sex (Male:Female) 204:244 (46%:54%)
Age, yr (Mean ± SD) 59.4 ± 16.5
Emergency department 317 (71%)
In-Hospital (Medical wards & ICU) 131 (29%)

36
Table 2: Stroke mimics seen in the emergency department vs. in-hospital
Emergency Department In-Hospital
Year Brain Attack Stroke Brain Attack Stroke
% %
Codes Mimics Codes Mimics
2014 313 88 28.11 58 31 53.44
2015 348 79 22.70 55 22 40.0
2016 281 75 26.69 52 31 59.61
2017 307 75 19.81 71 47 66.20
Total 1,249 317 25.38% 236 131 55.50%

Table 3: Most common etiologies of stroke mimics from 2014 – 2017

Categories 2014 2015 2016 2017 Total (%)
Encephalopathy 21 16 21 25 83 (18.5)
Seizures 26 16 20 15 77 (17.2)
Headache 17 6 3 5 31 (6.9)
Hypertensive emergency 13 1 8 9 31 (6.9)
Radiculopathy 0 8 9 10 27 (6.0)
Peripheral vertigo 9 5 4 6 24 (5.4)
Syncope 7 4 3 7 21 (4.7)
Bell’s palsy 3 3 3 7 16 (3.6)
Anxiety 3 7 2 2 14 (3.1)
Brain metastases 2 5 5 1 13 (2.9)
Transient global amnesia 0 5 2 5 12 (2.7)
Others 18 25 26 30 99 (22.1)
119 101 106 122 448 (100%)

Table 4: Top 10 most common stroke mimics in the emergency department from 2014 – 2017
Categories 2014 2015 2016 2017 Total %
Seizures 20 12 8 3 43 (13.6%)
Encephalopathy 6 7 12 7 32 (10.1%)
Headache 17 6 3 5 31 (9.8%)
Hypertensive emergency 10 1 8 8 27 (8.5%)
Radiculopathy 0 8 6 9 23 (7.3%)
Peripheral vertigo 8 5 4 6 23 (7.3%)
Bell’s palsy 3 3 3 7 16 (5.0%)
Syncope 6 4 2 3 15 (4.6%)
Anxiety 3 6 2 2 13 (4.1%)
Transient global amnesia 0 5 2 4 11 (3.5%)
Brain metastases 1 5 3 1 10 (3.2%)
Others 14 17 22 20 73 (23%)

the results of a published study on a 10-year patients examined by the stroke team in both the
data from the National Institute of Health Stroke emergency department and in the wards. However,
Program5 comprising of 8187 patients, which the incidence of stroke mimics in our institution
showed that stroke mimics account for 30% of was relatively higher in comparison to Japan,

37
Neurology Asia March 2021

Table 5: Top 10 most common stroke mimics in hospitalized patients from 2014 – 2017
Categories 2014 2015 2016 2017 Total
Encephalopathy 15 9 9 18 51 (38.9%)
Seizures 6 4 12 12 34 (25.9%)
Infection 0 1 1 6 8 (6.1%)
Syncope 1 0 1 4 6 (4.6%)
Radiculopathy 0 0 3 1 4 (3.1%)
Hypertensive emergency 3 0 0 1 4 (3.1%)
Brain metastases 1 0 2 0 3 (2.3%)
Subdural hemorrhage 1 0 1 1 3 (2.3%)
Cardiac (MI, arrhythmia) 1 1 0 1 3 (2.3%)
Electrolyte imbalance 2 0 0 0 2 (1.5%)
Others 1 7 2 3 13 (9.9%)

wherein the incidence of stroke mimics ranged sensorium, or focal neurologic deficits such as
from 7% - 8.8%5,6 and Tanzania (6.6%).7 Our study aphasia, hemisensory deficits, hemiparesis and
also showed that the incidence of stroke mimics presence of a toe-extensor signs.10,11 Moreover, the
was higher among hospitalized inpatients (either at frequency of this diagnosis in our hospital is much
the medical wards or in the intensive care units), higher among inpatients compared to patients
compared to patients who sought consult in the seen at the emergency room (38.9% vs 10.1%).
emergency department (55.5% vs. 25.3%). Similar These can be attributed to other comorbidities,
findings were seen in a previous study wherein such as electrolyte imbalances and infections,
stroke mimics accounted for 63.4% of in-hospital of the patients who are already admitted in the
stroke codes compared to 31.3% of stroke codes hospital for causes other than stroke.
activated in the emergency department.9 Another common stroke mimic is seizure.
The most common etiologies of stroke mimics A seizure episode is one of the most common
in our hospital were encephalopathy, seizures, stroke mimics encountered in the emergency
headache, and hypertensive emergencies and department and in the wards.12 In our hospital,
radiculopathy. The most common etiology of seizures accounted for 17% of all stroke mimics
stroke mimic among inpatients in our hospital while in a study done at a tertiary university
is encephalopathy, which is characterized by hospital in Spain, seizures comprise more than
functional alteration of mental status due to one-fourth (26%) of all stroke mimics.8 After a
systemic disease. Metabolic (hypoglycemia, seizure attack, Todd’s paralysis occurs, which can
hepatic, uremic) or electrolyte derangements persist for several hours. Hence, it was postulated
(hyponatremia) may present with decreased that the persistence of hemiparesis and other post-

Table 6: Total and average cost of diagnostics for stroke mimics from 2014 – 2017
Total Costs, PHP Average cost per patient, PHP
Year
(USD*) (USD*)
2014 3,079,093.76 25,874.74
(61,581.87) (517.50)
2015 2,449,746.42 24,254.92
(48,994.93) (485.09)
2016 2,520,569.74 23,778.96
(50,411.39) (475.58)
2017 2,984,621.66 24,464.11
(59,692.43) (489.28)
Total 11,034,031.58 24,629.53
(220,680.63) (492.59)
*Exchange rate: PHP 50 = 1 USD

38
ictal symptoms such as drowsiness or confusion diagnostic costs and minimize the potential
is usually misidentified as a stroke symptom. adverse effects of intravenous thrombolysis.
It is critical to distinguish stroke mimics from
actual strokes in order to avoid the potentially DISCLOSURE
harmful effects of intravenous thrombolysis as
well as to minimize the hospital costs (direct Financial support: None
and indirect) of diagnostics, medications, and Conflict of interest: None
admission to critical care or acute stroke units.
Our study showed that each patient spent
REFERENCES
PHP24,629.53 (approximately US$500) for
laboratory tests and imaging procedures. In a 1. N a v a r r o J C , B a r o q u e A C , L o k i n J K ,
low middle-income country (LMIC) such as the Venketasubramanian N. The real stroke burden in
Philippines, with an estimated GDP per capita the Philippines. Int J Stroke 2014; 9(5):640-1.
2. Magauran BG Jr, Nitka M. Stroke mimics. Emerg.
of US$3500 (World Bank 2019), the average Med. Clin. North Am 2012; 30: 795-804
cost per patient for the diagnostics (laboratory 3. Gibson LM, Whiteley W. The differential diagnosis
tests and imaging) alone is significant because of suspected stroke: a systematic review. J R Coll
in terms of health financing sources, majority is Physicians Edinb 2012; 43:114-8.
still via household out-of-pocket payment (57%) 4. Merino JG, Luby M, Benson R, et al. Predictors
and national health insurance system (12%).13 In of acute stroke mimics in 8187 patients referred to
a stroke service. J Stroke Cerebrovasc Dis 2013;
comparison, a study done in the United States
22:397-403.
calculated the direct hospital costs incurred by 5. Sato T, Komuro T, Kobayashi A, et al. Stroke mimics
patients who were given intravenous recombinant admitted to neurosurgery ward. Prog. Med 2014; 34:
tissue plasminogen activator but were eventually 793-9
diagnosed as stroke mimics, showed that each 6. Okano Y, Ishimatsu K, Kato Y, Yamaga J, Kuwahara
patient incurred costs amounting to approximately K, Okumoto K. Clinical features of stroke mimics in
US$5400.14 the emergency department. Acute Med Surg 2018;
5(3): 241-8.
Our study has limitations. We only included 7. Matuja SS, Khanbhai K, Mahawish KM, Munseri
patients who were examined and diagnosed as P. Stroke mimics in patients clinically diagnosed
stroke mimics by the Brain Attack Team. Hence, with stroke at a tertiary teaching hospital in
stroke mimics in patients who sought consult Tanzania: a prospective cohort study. BMC Neurol
and were examined > 6 hours from ictus were 2020;20(1):270.
not included in the analysis. The study did not 8. Avellaneda-Gómez C, Rodríguez Campello A, Giralt
analyze the risk factors that would predict the Steinhauer E, et al. Description of stroke mimics
after complete neurovascular assessment. Neurologia
probability that a patient is a stroke mimic rather 2019;34(1):7-13.
than an actual stroke. Lastly, indirect healthcare 9. El Husseini N, & Goldstein LB. “Code stroke”:
costs on the part of the hospital (e.g. manpower hospitalized versus emergency department patients.
hours and constraints on nursing and healthcare J Stroke Cerebrovasc Dis 2013; 22(4):345-8.
staff), as well as on the part of the patient (e.g. 10. Libman RB, Wirkowski E, Alvir J, et al.. Conditions
loss of productivity and lost wages), were not that mimic stroke in the emergency department.
Implications for acute stroke trials. Arch. Neurol
calculated in this study.
1995;52:1119-22.
This is the first study to describe the profile of 11. Hosseininezhad M, Sohrabnejad R. Stroke mimics
stroke mimics in terms of incidence, most common in patients with clinical signs of stroke. Caspian J
etiologies and diagnostic costs in the Philippines Intern Med 2017;8(3):213-6.
and in Southeast Asia. The differentiation of 12. Zinkstok SM, Engelter ST, Gensicke H et al. Safety
stroke mimics from actual stroke pose a common of thorombosis in stroke mimics: results from a
clinical challenge in the emergency setting and multicenter cohort study. Stroke 2013;44:1080-4.
13. Republic of the Philippines. Department of Health.
inpatient, as shown by the high incidence of stroke National Objectives for Health 2011 – 2016. Chapter
mimics in our institution and the wide range of 1. The Philippine health system at a glance. Accessed
medical and neurological conditions that mimic on August 4, 2020 <http://www.doh.gov.ph/sites/
the symptoms of stroke. The substantial costs default/files/basic-page/chapter-one.pdf>
incurred for diagnostics highlight the need for 14. Goyal N, Male S, Al Wafai A, Bellamkonda S, Zand R.
frontline healthcare personnel (physicians and Cost burden of stroke mimics and transient ischemic
nurses) to be highly cognizant of the symptoms of attack after intravenous tissue plasminogen activator
treatment. J Stroke Cerebrov Dis 2015; 24(4):828-3.
stroke vis-à-vis stroke mimics. Early recognition
of stroke mimics can reduce hospitalization and

39