Introduction: Headache (HA) is more commonly associated with stroke mimics than with acute ischemic stroke (AIS). Acute neurological deficit associated with HA at presentation during “Stroke Alert” may adversely affect decision to undertake intravenous (IV) thrombolysis. Advocacy of rapid and early IV thrombolysis for AIS may lead to inappropriate use of such therapy for stroke mimics rather than for AIS.
Hypothesis: Headache associated with acute neurological deficit during “Stroke Alert” is less likely to receive thrombolytic therapy as compared to those without headache.
Methods: We performed chart review of all adult patients presenting with “Stroke Alert” at our comprehensive stroke center in 2013. During this period our imaging protocol for IV tissue plasminogen activator administration (tPA) included non-contrast head CT. We compared the IV tPA administration rate in patients with and without HA and also evaluated patients receiving and missing IV tPA for respective diagnoses.
Results: At our institution, 331 patients presented as “Stroke Alert” in 2013. Ninety (28%) patients reported HA at presentation. IV tPA was administered to 51 “Stroke Alert” patients (15.4%). Only 5/90 patients (5.55%) who presented with HA received IV tPA compared to 46/241 patients (19.1%) who did not present with HA (p =0.018). None of the patients with HA who received IV tPA had AIS on subsequent imaging as compared to 6/85 in patients with HA who did not receive IV tPA (Odd ratio 1.11, CI; 0.055 to 22.411, p=0.94). The median NIHSS was 5 in the HA and IV tPA group compared to 2.5 in the HA and no-IV tPA group. The discharge diagnosis in the HA and no- IV tPA group was migraine in 51 (60.7%), intracranial hemorrhage in 11 (13.1%), AIS in 6 (7.05%) and toxic metabolic encephalopathy in 4 (4.7%) patients. None of the stroke mimic patients who received IV tPA had hemorrhagic complications. The probability of “Stroke Alert” patient with HA being correctly diagnosed with AIS was 6.67% and receiving IV tPA was 5.56%.
Conclusion: Likelihood of “Stroke Alert” patients with headache and acute neurological deficits being treated with IV thrombolysis is low. Incidence of AIS in patients with HA and acute neurological deficits not treated with thrombolysis was equally low which is reassuring.