Stroke Mimics in a Tertiary Comprehensive Stroke Center: Implications for Healthcare Provider Education

Background: The proportion of stroke mimics in code stroke activation varies.Decreasing the number of stroke mimics requires clinicians to master the skills needed to distinguish strokes from stroke mimics.There is a lack of quality initiatives to produce such astute clinicians, who, once trained, should improve the accuracy of stroke alerts, reduce patient risk from unnecessary radiation, optimize resource utilization, and correctly diagnose patients to provide the best treatment course.Methodology: As a comprehensive stroke program, stroke data were collected as part of the continuous quality control and improvement procedures.A retrospective study from January 2026 to June 2026 was conducted using the original stroke database to select patients with code stroke activation who were treated with the code stroke protocol and their final diagnoses at discharge.No individual patient data were reviewed.No inferential statistical analyses were performed.Results: From January 2026 to June 2026, there were a total of 630 code stroke activations (mean = 105 patients/month; range = 86-120 patients).True strokes accounted for 35.1% (221/630, 35.1%) of the code stroke activations, yielding 64.9% (409/630, 64.9%) stroke mimics.Among stroke patients, 110/630 (17.5%) were ischemic strokes, 96/630 (15.2%) were transient ischemic attacks, 14/630 (2.2%) were intracerebral hemorrhages, and 1/630 (0.2%) was a subarachnoid hemorrhage.The stroke mimics were sepsis (36/630, 5.7%), migraine (29/630, 4.6%), seizure (21/630, 3.3%), subdural hematoma (21/630, 3.3%), hypertensive emergency/crisis (21/630, 3.3%), residual deficits from prior stroke (18/630, 2.9%), unruptured aneurysm (13/630, 2.1%), alcohol abuse/other drug use/mental illness (12/630, 1.9%), Bell's palsy (9/630, 1.4%), and all other diagnoses (229/630, 36.3%).Conclusions: In this study, stroke mimics accounted for 409/630 (64.9%) of code stroke activations, which is higher than documented in the literature and in past performance at this institution.The most likely stroke mimics are sepsis, migraine, seizure, subdural hematoma, and hypertensive emergency/crisis.Parallel increases in public awareness and education on stroke and lifelong education on acute stroke recognition must continue for all clinicians to accurately identify patients with acute strokes, for which a large amount of hospital resources is used for code stroke activation.Future studies should investigate methods to efficiently diagnose patients and optimize healthcare resources.