Clinical Predictors of Stroke Mimics in Code Stroke Patients Evaluated via Telemedicine and Treated With Thrombolytic Therapy

Background Intravenous thrombolysis is an established treatment to improve functional outcomes in acute ischemic stroke. However, various acute central nervous system dysfunctions can mimic stroke, where thrombolytic therapy may provide no benefit and carries potential risks. The ability to accurately distinguish stroke mimics vs stroke by telemedicine evaluation is uncertain. This study aims to identify clinical predictors of stroke mimics in patients evaluated via telemedicine for suspected ischemic stroke and treated with thrombolytics. Methods We conducted a retrospective observational study of patients treated with thrombolytics for suspected acute ischemic stroke via telemedicine at Southern Illinois Healthcare between 2017 and 2024. Data on demographics, past medical history, clinical presentation, National Institutes of Health Stroke Scale (NIHSS), stroke metrics, and laboratory values were collected. Final diagnoses were categorized as cerebrovascular disease (CD), including acute ischemic stroke and transient ischemic attack, and stroke mimic (SM). Outcomes included hospital length of stay (LOS) and discharge disposition. Results Of 171 patients treated with thrombolytics via telemedicine, 128 (75%) were diagnosed with CD, and 43 (25%) were SM, with toxic-metabolic encephalopathy being the most common mimic (40%, n = 17). Adjusted forward logistic regression showed age (OR: 0.957, 95% CI: 0.931-0.984, P = .002) and NIHSS (OR: 1.098, 95% CI: 1.032-1.168, P = .003) remained independently associated with SM. The predictive TeleStroke Mimic was score performed with c-statistic of 0.61. SM had shorter median LOS (3 [2-3] vs 3 [2-6], P < .01) and higher rate of discharge home (86% vs 55%, P < .01). Conclusions In our population, younger age and higher NIHSS were associated with higher odds of SM diagnosis in patients treated with telemedicine-administered thrombolytics. These variables are insufficient to reliably identify a subgroup of patients evaluated via telemedicine for whom thrombolytics could be withheld. The poor performance of Telestroke Mimic score highlights the need for improved predictive tools. Until larger studies are conducted, telemedicine-administered thrombolytics should adhere to current in-person guidelines.