• Sudden and maximal onset of stroke symptoms
• Decreased level of consciousness
• Large vessel occlusion (anterior, middle, or posterior cerebral arteries, and the carotid, vertebral, or basilar arteries)
• Wernicke or global aphasia without hemiparesis

In a patient where embolic stroke is suspected, additional workup is warranted and may benefit the patient. A full set of vital signs (including a temperature), ECG, laboratory diagnostics, CT angiography of the brain extending from the aortic arch, a bedside echocardiogram or point-of-care ultrasound, and possible early cardiology consultation are essential components of the evaluation. Treatment decisions must be in concert with neurology colleagues.

• Common treatable causes of embolic stoke seen in the emergency department include:
• New-onset atrial fibrillation
• Recent myocardial infarction
• Infective endocarditis with septic emboli
• Carotid, vertebral, basilar, or aortic dissection

Along with true cerebrovascular accident, emergency physicians must be aware of the many potential stroke mimics. The list is not exhaustive, but some common mimics include hypoglycemia, Todd’s paralysis, migraines, malignancy, factitious disorder/malingering, and many others.2,3 Prior to heading down a typical stroke treatment algorithm, pause to consider these alternative diagnoses.

Discussion

Cerebrovascular accident is a commonly encountered and severely debilitating disease. As we protocolize early stroke management, diagnostic anchoring to “just” a stroke and lack of investigation into stroke mimics or secondary causes of stroke are real risks. Strokes that are embolic in nature can originate from a variety of causes, which will likely alter the overall approach and management of the patient. It is imperative that emergency physicians identify which patients may have an embolic stroke and investigate for reversible or treatable causes. Although not every stroke patient will have a source identified beyond traditional atherosclerotic disease, consideration of secondary causes has the potential to benefit our patients greatly. In short, all strokes are not created equal.

Dr. Isenburg is an emergency medicine resident at St. Joseph’s University Medical Center in Paterson, New Jersey.

Dr. Boothe is an emergency and palliative care physician at St. Joseph’s University Medical Center.

References

1. Arboix A, Alio J. Acute cardioembolic cerebral infarction: answers to clinical questions. Curr Cardiol Rev. 2012;8(1):54-67.
2. Merino JG, Luby M, Benson RT, et al. Predictors of acute stroke mimics in 8187 patients referred to a stroke service. J Stroke Cerebrovasc Dis. 2013;22(8):e397-e403.
3. Tobin WO, Hentz JG, Bobrow BJ, et al. Identification of stroke mimics in the emergency department setting. J Brain Dis. 2009;1:19-22.