Introduction: The ongoing Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial (RIGHT-2) is testing the safety and efficacy of paramedic-delivered transdermal glyceryl trinitrate (GTN) in patients with ultra-acute stroke. We sought to assess whether stroke mimics have a benign outcome in comparison to stroke patients.
Methods: RIGHT-2 is an ongoing prospective randomised single-blind blinded-endpoint parallel group trial enrolling 1050 previously independently patients with suspected stroke (Face Arm Speech Test score ≥2/3) within 4 hours of onset. Consenting patients are randomised to receive GTN or sham patch in the pre-hospital setting. The primary outcome is the modified Rankin scale (mRS) assessed at day 90. Data are number (%) or mean (standard deviation).
Results: As of July 2017, 600 patients had been recruited of which 146 (24.3%) were stroke mimics. Mimics were younger, age 65.1 (18.1) years; had a lower NIHSS 5.6 (6.3) vs 11.4 (7.4); and higher Glasgow coma scale, 14.3 (1.8) vs 13.6 (2.3) than stroke participants. The most common diagnoses were: seizure (16%), migraine/headache (16%) and functional (10%). Of those who have completed day 90 follow-up compared with stroke, mimics had significantly better functional outcome, mRS 2.6 (2.0) vs 3.9 (1.8), p<0.0001, and quality of life, and lower disability and depression scores, and a lower death rate, 11 (12.1%) vs 73 (26.4%), p=0.0047.
Conclusion: Although their outcome is better than stroke participants, mimics do not necessarily have benign outcomes. Pragmatic pre-hospital trials with safety data on mimics may ultimately ease implementation of interventions into clinical practice.