Prehospital Emergency Care

ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20

Characterizing Strokes and Stroke Mimics

Transported by Helicopter Emergency Medical
Services

Denisse Sequeira BS, Christian Martin-Gill MD, MPH, Matthew R. Kesinger

BA, Laura R. Thompson MD, MS, Tudor G. Jovin MD, Lori M. Massaro MSN,
CRNP & Francis X. Guyette MD, MPH

To cite this article: Denisse Sequeira BS, Christian Martin-Gill MD, MPH, Matthew R.
Kesinger BA, Laura R. Thompson MD, MS, Tudor G. Jovin MD, Lori M. Massaro MSN,
CRNP & Francis X. Guyette MD, MPH (2016): Characterizing Strokes and Stroke Mimics
Transported by Helicopter Emergency Medical Services, Prehospital Emergency Care, DOI:
10.3109/10903127.2016.1168889

To link to this article: http://dx.doi.org/10.3109/10903127.2016.1168889

Published online: 15 Apr 2016.

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 CHARACTERIZING STROKES AND STROKE MIMICS TRANSPORTED BY
HELICOPTER EMERGENCY MEDICAL SERVICES
Denisse Sequeira, BS, Christian Martin-Gill, MD, MPH, Matthew R. Kesinger, BA,
Laura R. Thompson, MD, MS, Tudor G. Jovin, MD, Lori M. Massaro, MSN, CRNP,
Francis X. Guyette, MD, MPH
ABSTRACT
Objective: Stroke is the leading cause of disability in the
United States with most of these patients being transported
by emergency medical services. These providers are the first
medical point of contact and must be able to rapidly and
accurately identify stroke and transport these patients to
the appropriate facilities for treatment. There are many con-
ditions that have similar presentations to stroke and can
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be mistakenly identified as potential strokes, thereby af-
fecting the initial prehospital triage. Methods: A retrospec-
tive observational study examined patients with suspected
strokes transported to a single comprehensive stroke center
(CSC) by a helicopter emergency medical service (HEMS)
agency from 2007 through 2013. Final diagnosis was ex-
tracted from the Get with the Guidelines (GWTG) database
and hospital discharge diagnosis for those not included in
the database. Frequencies of discharge diagnosis were cal-
culated and then stratified into interfacility vs. scene trans-
fers. Results: In this study 6,243 patients were transported:
3,376 patients were screened as potential strokes, of which
2,527 had a final diagnosis of stroke (2,242 ischemic stroke
and 285 transient ischemic attack), 166 had intracranial hem-
orrhage, and 655 were stroke mimics. Stroke mimics were
more common among scene transfers (223, 32%) than among
interfacility transfers (432, 16%). Conclusions: In our study
approximately 20% of potential stroke patients transported
via HEMS were mimics. Identifying the need for CSC re-
sources can be an important factor in creating a prehospi-
tal triage tool to facilitate patient transport to an appropri-
ate health care facility. Key words: stroke; helicopter; emer-
gency medical services
PREHOSPITAL EMERGENCY CARE 2016;Early Online:1–6
Received August 4, 2015 from University of Pittsburgh, Department
of Emergency Medicine, Pittsburgh, Pennsylvania (DS,CM-G, FXG);
University of Pittsburgh, School of Medicine, Pittsburgh, Pennsyl-
vania (MRK); The Ohio State University, Department of Emergency
Medicine, Columbus, Ohio (LRT); University of Pittsburgh, Depart-
ment of Neurology, Pittsburgh, Pennsylvania (TGJ, LMM). Revision
received March 8, 2016; accepted for publication March 9, 2016.
Address correspondence to Denisse Sequeira, 3600 Forbes
Ave., Suite 400A, Pittsburgh, PA 15213, USA. E-mail:
sequeirad@upmc.edu
doi: 10.3109/10903127.2016.1168889
1
INTRODUCTION
Stroke is one of the leading causes of disability in the
United States, affecting approximately 780,000 people
and contributing to 130,000 deaths annually.1 As many
as 80% of stroke patients enter the medical system
through emergency medical services (EMS), and cur-
rent guidelines recommend that EMS providers triage
and rapidly transport suspected stroke patients to des-
ignated facilities.2 Helicopter emergency medical ser-
vices (HEMS) are increasingly used to transport non-
trauma patients including suspected strokes to facil-
ities with stroke specialty services.3 It is crucial for
these providers to accurately and rapidly identify po-
tential stroke patients in order to transport them to ap-
propriate stroke centers, reduce delays, and maximize
the likelihood of treatment with interventions includ-
ing tissue plasminogen activator (tPA) or mechanical
thrombectomy.4 Common barriers to correct identifica-
tion are conditions that have clinically similar presen-
tations to stroke, known as “stroke mimics.” Previous
studies have demonstrated a widely variable incidence
of stroke mimics ranging from 1.5% in the hospital set-
ting to up to 30% in out-of-hospital studies.5–7
There are numerous costs associated with over-
triage of patients transported to tertiary centers. Trans-
port over long distances exposes patients to the risks of
transport, stresses patient support networks, and may
disrupt critical resources at the stroke center. Given
these potential costs, knowledge of the epidemiology
of stroke mimics can inform prehospital triage proto-
cols within regionalized health care systems. We aimed
to determine the incidence and characteristics of stroke
mimics in a population of patients with stroke-like
symptoms transported by HEMS to a comprehensive
stroke center (CSC).
METHODS
We performed a retrospective observational study of
potential stroke patients transported to a single CSC by
a HEMS agency from 2007 through 2013. This HEMS
agency is an inter-state critical care transport service
that averages 11,000 transports annually. Ground EMS
units in this region are primarily staffed by an EMT
and a paramedic. Ground units often call HEMS for
strokes due to distance to appropriate stroke centers.
 2 PREHOSPITAL EMERGENCY CARE
In addition, transportation of patients during or af-
ter the administration of tPA requires critical care
providers available through HEMS agencies. All cases
were documented in an electronic patient care report-
ing program (emsCharts, Inc., Warrendale, PA). Inclu-
sion of records was based on the medical category
documented in the prehospital medical record, which
changed after 2010, when a specific “stroke/cva” cat-
egory was used. Cases were selected if categorized as
suspected “stroke/cva” (after 2010) or if the medical
category was “neurological” complaint and any ele-
ment of the Cincinnati Prehospital Stroke Scale (CPSS)
was positive (cases before 2010). CPSS was abstracted
from the electronic prehospital medical record. An in-
vestigator (DS) with three years of stroke research ex-
perience as well as NIHSS certification first analyzed
the charts to identify cases with criteria meeting the
CPSS diagnosis; a clinician (FG) then checked a 10%
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sample, and inter-rater agreement was 92.6% (kappa
= 0.85). Patients with a documented intracranial hem-
orrhage (ICH) at the time of transport were excluded.
A secondary analysis described the incidence of diag-
noses other than ischemic stroke or TIA for patients
who received tPA and a telemedicine consult prior to
arrival. This was done to allow the comparison of mim-
ics among patients with and without telemedicine in-
tervention. We excluded patients with a CT-confirmed
ICH at time of transport as our focus was to identify
those patients with acute ischemic stroke that may ben-
efit from intervention.
We used probabilistic linkage to match the HEMS
records to the Get with the Guidelines (GWTG) hospi-
tal database that includes all diagnoses as determined
by a neurologist. Probabilistic linkage was done using
patient age, sex, and date of first neurologic exami-
nation, which provided a high degree of fidelity. The
database did not include all types of diagnoses beyond
neurological. Cases with a final diagnosis of transient
ischemic attack (TIA) were grouped with strokes. For
cases not found in the GWTG database, such as syn-
cope, the hospital chart was manually reviewed for
final discharge diagnosis recorded by the neurology
stroke team.
Data were analyzed by descriptive statistics. Fre-
quencies of discharge diagnosis were calculated and
then stratified by interfacility transfers vs. scene trans-
fers. A Fisher’s exact test was performed on relevant
comparisons. All statistical analysis was performed us-
ing software STATA version 12.
The University of Pittsburgh Institutional Review
Board approved the study as minimal risk with a
waiver of the requirement to obtain informed consent.
RESULTS
From 2007 through 2013, 6,243 patients were trans-
ported to a single CSC via HEMS for neurological com-
2016 EARLY ONLINE
plaints. Of these, 5,377 were interfacility transfers and
866 were scene runs. After chart review, 2,867 were ex-
cluded based on a negative CPSS resulting in 3,376 pa-
tients transported with stroke-like symptoms for anal-
ysis (Figure 1). Of these, 2,527 (74.8%) had a stroke,
166 (4.9%) were ICH, 655 (19.4%) were stroke mim-
ics, and 28 had insufficient data to determine final di-
agnosis. Of the 2,527 strokes, 2,242 (88.7%) were is-
chemic strokes and 285 (11.3%) were TIAs. Figure 2
illustrates the final discharge diagnoses by percent-
ages. The most frequent mimic diagnoses were seizure
(N = 126, 3.8%), altered mental status (N = 82, 2.4%),
and weakness (N = 75, 2.2%). In the secondary anal-
ysis of patients who were administered tPA prior to
arrival, 6.9% had a final diagnosis other than ischemic
stroke or TIA. A lower percentage of patients who re-
ceived telemedicine consult had stroke mimics com-
pared to the overall cohort (13.2% vs. 19.4%, p < 0.05).
Hemorrhages were largely intra-parenchymal hemor-
rhages although there was a small subset of subarach-
noid hemorrhages (N = 22) and subdural hematomas
(N = 8).
Table 1 presents the descriptive statistics of the study
population. Compared to men, women had a greater
proportion of mimics (23% vs. 17%, p < 0.001) and a
lower proportion of ischemic strokes (64% vs. 69%, p
= 0.002). Of the patients transported from the scene,
223 (32%) were mimics while 396 (56%) had ischemic
events. Of the interfacility transfers, 432 (16%) were
mimics while 2,131 (81%) were ischemic events. The
percentage of mimics among scene transports was
higher (32% vs. 16%, p < 0.001)
Facial palsy is an important factor in prehospi-
tal stroke diagnostic tools including the Los Ange-
les Prehospital Stroke Screen (LAPSS) and the CPSS.
In our cohort, facial palsy associated final diagnosis
was present in only 2.1% of the total mimics, some
of which were Bell’s palsy (57.1% of total facial palsy,
1.2% of total mimic population). Additionally, condi-
tions that are potentially identifiable in the prehospital
environment such as hypoglycemia and intoxication
were rare, each with frequencies less than 2% of total
mimics.
DISCUSSION
This study provides a broad characterization of pa-
tients with suspected stroke transported to a compre-
hensive stroke center by air medical services. The in-
cidence of stroke mimics in our population was 19.6%.
Patients transported directly from the scene were more
likely to present with a stroke mimic then those trans-
ported from a referring hospital. These data provide
information that can inform triage protocols that aim
to maximize transport of ischemic stroke patients to
designated facilities, while minimizing unnecessary
over-triage of patients away from community hospi-
 D. Sequeira et al. STROKE MIMICS TRANSPORTED BY HELICOPTER EMS
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FIGURE 1. Patient flow diagram.
tals that are equipped to care for a subset of these
patients.
Timely and accurate identification of stroke influ-
ences the timeliness of stroke treatment.8,9 Despite a
20-year emphasis on using tPA for ischemic stroke,
its use remains low at 3–15%.10–12 Inappropriate ini-
tial triage, concerns of over-triage, and other delays
decrease the use and effectiveness of treatment with
tPA.13–16 Newly published data on the benefits of in-
vasive catheter based therapies for stroke have fur-
ther highlighted the importance of accurate prehospi-
3
tal stroke triage.17–21 These randomized controlled tri-
als differ from prior studies showing no benefit of tPA
vs. endovascular therapy by demonstrating a marked
benefit of endovascular procedures for patients with
large vessel occlusion independent of tPA administra-
tion. This is rapidly making endovascular procedures
the standard at most comprehensive stroke centers. Be-
cause the benefit of endovascular reperfusion is also
time dependent,22,23 appropriate triage of patients to
CSCs is becoming a challenge of paramount impor-
tance for stroke systems of care.
 4 PREHOSPITAL EMERGENCY CARE 2016 EARLY ONLINE
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FIGURE 2. Final diagnoses by percentages.

Accurate field triage that maximizes use of benefi-
cial specialty interventions and minimizes their unnec-
essary use has been emphasized in other regionalized
systems of care. Prehospital activation of the cardiac
catheterization lab for patients with ST segment ele-
vation myocardial infarction (STEMI) is widely sup-
ported, even with false positive rates of 15–33%.24–26
Similarly, the American College of Surgeons Commit-
tee on Trauma has identified an acceptable over-triage
rate of up to 35% for referral to trauma centers.27 Yet
the activation of specialty resources for common mim-
ics found in this study, such as altered mental sta-
tus, weakness, and syncope, could negatively affect the
care of other patients at tertiary centers, as occurs with
trauma activations.28,29 The optimal over- and under-
triage rates for transport of patients to stroke centers
are unknown and unlikely to be the same as STEMI or
trauma. Stroke care is unique in that patients may be
treated with tPA at community hospitals, while only a
subset will benefit from time-dependent interventions
available at tertiary centers.
In addition to initial and continued treatment of
ischemic stroke, CSCs also have specialized services
including neuro-critical care, neurosurgical interven-
tion, enhanced diagnostics, and rehabilitation that may
be helpful in the management of stroke mimics such
as ICH, seizure, and hemiplegic headache. For ex-
ample, of those with a final diagnosis of headache,
we found 87.8% were hemiplegic headache, a condi-
tion in which patients may display stroke-like symp-
toms and require specialist evaluation to differentiate
them from TIAs.30 Previous prehospital studies have

TABLE 1. Sample Demographics

All Patients Interfacility Scene Run
Feature n = 3354† n = 2647 n = 707

Telemedicine n = 166 Without Telemedicine

n = 2481
Mean age (IQR) 67 (55–78) 66 (57–79) 65 (54–77) 69 (56–79)
Sex, male (%) 1677 (50.3) 80 (48) 1247 (50.4) 351 (51%)
NIH Stroke Scale (Mean, IQR) 9.6 (3–15) 11.7 (4–18) 8.8 (2–14) 11.1 (4–16)
Telemedicine consult n (%; CI) 166 (5; 4.2–5.7) -
Intravenous t-PA n (%; CI) 735 (22; 20.5–23.3) 106 (64; 56.4–71.2) 612 (25; 22.9–26.3) 17 (2; 1.3–3.5)
Intra-arterial intervention n (%; 232 (6.9; 6.1–7.8) 32 (19; 13.2–25.3) 167 (7; 5.7–7.7) 33 (5; 3.1–6.2)
CI)
Final Diagnosis‡
Ischemic stroke∗ n (%; CI) 2527 (75; 74.0–76.9) 144 (87; 81.5–92.0) 1987 (80.5; 79.0–82.0) 396 (56.0; 52.3–59.7)
Hemorrhage n (%; CI) 166 (5.0; 4.2–5.7) 0 78 (3.0; 2.3–3.6) 88 (12.4; 10.0–14.9)
Stroke mimic n (%; CI) 655 (19.5; 18.2–20.9) 22 (13; 8.0–18.4) 410 (16.3; 14.9–17.8) 223 (31.5; 28.1–35.0)
Most Frequent Mimics
Seizure (n,%) 126 (3.7) 6 (4) 67 (2.7) 53 (7.5)
Altered mental status (n,%) 82 (2.4) 0 45 (1.8) 37 (5.2)
Weakness (n,%) 75 (2.2) 6 (4) 43 (1.7) 26 (3.7)
∗
Includes those with TIA diagnosis; †Includes 28 patients with insufficient data to find final diagnosis; ‡A total of 6 patients had t-PA listed in the prehospital chart
but did not have final diagnoses.
 D. Sequeira et al. STROKE MIMICS TRANSPORTED BY HELICOPTER EMS
demonstrated the limited performance of commonly
used stroke triage scales (LAPSS, CPSS).31,32 There is
a need for better tools that accurately identify action-
able strokes and also differentiate patients with mim-
ics that can be safely managed at community hospitals
from those needing tertiary care.
The increasing prevalence of telemedicine as an ini-
tial stroke triage tool has shown promising results, al-
though it is not yet available in all facilities.33,34 Ambu-
lance based telemedicine similarly holds promise for
prehospital stroke triage, particularly to identify the
likely need of time-dependent interventions available
at distant sites. However, while telemedicine increases
the diagnostic accuracy of stroke identification and
severity, conditions such as Todd’s paralysis, hemi-
plegic migraine, and functional deficits remain difficult
to differentiate from a stroke based on a remote clini-
cal exam. Future studies should identify to what ex-
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tent telemedicine can differentiate stroke mimics that
would otherwise be referred to a CSC. The described
incidence of mimics in these patients provided in this
study can help to inform this future investigation and
the development of newer tools that can improve pre-
hospital stroke triage.
LIMITATIONS
We limited our analysis to patients transported by a
regional critical care service, introducing a selection
bias based on patient acuity. Patients that need to be
transported by helicopter are generally believed to be
more severely ill than those transferred by ground. The
use of the CPSS as part of the inclusion criteria was
based on physical exam documentation in the trans-
port record, including performance of an NIH Stroke
Scale in most cases; individual elements of the CPSS
were not documented by the HEMS crew. Finally, some
discharge diagnoses such as altered mental status and
weakness are not sufficiently specific and would po-
tentially be more informative if we had higher res-
olution. These were included because they were the
recorded hospital discharge diagnoses taken as the
gold standard.
CONCLUSIONS
Mimics accounted for approximately 20% of HEMS
patients transferred for stroke-like symptoms. Future
triage tools should be focused on identifying need for
CSC, facilitating regionalization of stroke care and effi-
cient utilization of health care resources.
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