Ischemic stroke mimics: A comprehensive review

J Clin Neurosci. 2021 Nov:93:174-182. doi: 10.1016/j.jocn.2021.09.025. Epub 2021 Sep 20.


Background: Ischemic stroke is the leading cause of disability and one of the leading causes of death. Ischemic stroke mimics (SMs) can account for a noteble number of diagnosed acute strokes and even can be thrombolyzed.

Methods: The aim of our comprehensive review was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of SMs in stroke/thrombolysis situations.

Results: Overall, 61 studies were selected with 62.664 participants. Ischemic stroke mimic rate was 24.8% (15044/60703). Most common types included peripheral vestibular dysfunction in 23.2%, toxic/metabolic in 13.2%, seizure in 13%, functional disorder in 9.7% and migraine in 7.76%. Ischemic stroke mimic have less vascular risk factors, younger age, female predominance, lower (nearly normal) blood pressure, no or less severe symptoms compared to ischemic stroke patients (p < 0.05 in all cases). 61.7% of ischemic stroke patients were thrombolysed vs. 26.3% among SMs (p < 0.001). (p < 0.001). Overall intracranial hemorrhage was reported in 9.4% of stroke vs. 0.7% in SM patients (p < 0.001). Death occurred in 11.3% of stroke vs 1.9% of SM patients (p < 0.001). Excellent outcome was (mRS 0-1) was reported in 41.8% ischemic stroke patients vs. 68.9% SMs (p < 0.001). Apart from HINTS manouvre or Hoover sign there is no specific method in the identification of mimics. MRI DWI or perfusion imaging have a role in the setup of differential diagnosis, but merit further investigation.

Conclusion: Our article is among the first complex reviews focusing on ischemic stroke mimics. Although it underscores the safety of thrombolysis in this situation, but also draws attention to the need of patient evaluation by physicians experienced in the diagnosis of both ischemic stroke and SMs, especially in vertigo, headache, seizure and conversional disorders.

Keywords: Clinical findings; Etiology; Mimic; Outcome; Stroke; Thrombolysis.

Publication types

  • Review

MeSH terms

  • Brain Ischemia* / diagnosis
  • Brain Ischemia* / drug therapy
  • Brain Ischemia* / epidemiology
  • Female
  • Fibrinolytic Agents / therapeutic use
  • Humans
  • Ischemic Stroke*
  • Stroke* / diagnosis
  • Stroke* / drug therapy
  • Stroke* / epidemiology
  • Thrombolytic Therapy
  • Treatment Outcome


  • Fibrinolytic Agents