Clinical profiles of MRI-negative ischemia and stroke mimics after thrombolysis: insights into diagnostic uncertainty in acute ischemic stroke care

Intravenous thrombolysis (IVT) for suspected acute ischemic stroke is initiated before definitive imaging confirmation, resulting in treatment of patients later classified as MRI confirmed infarction (MRI +), MRI negative ischemia (MRI -), or stroke mimics. Characterization of MRI - and mimic presentations may support assessment under uncertainty.

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✦ The floor

Discussion

Signed responses from readers of the wire.

✦ Clinical Takeaway ✦

No actionable change for audiologists — this is a neurology/emergency medicine study, but vestibular clinicians should be aware that acute vertigo remains a leading stroke mimic and that their expertise in differentiating vestibular from central causes has real patient-safety implications.

✦ Why It Matters ✦

Vertigo is one of the most common stroke mimics leading to unnecessary thrombolysis, and this study highlights the urgent need for reliable bedside tools — including vestibular assessment — to distinguish central from peripheral causes in the ED.

✦ Key Points ✦

01Retrospective study examining patients treated with thrombolysis who turned out not to have ischemic stroke (stroke mimics).
02Vertigo is identified as a common presenting symptom in stroke mimic cases, creating diagnostic uncertainty.
03MRI-negative ischemia represents a distinct diagnostic challenge separate from stroke mimics.
04Highlights patient safety risks of both over- and under-treatment with thrombolysis in ambiguous cases.
05Vestibular testing expertise (e.g., HINTS exam) may be critical in preventing misdiagnosis in these settings.

✦ Claims & Evidence ✦

ClaimEvidenceSupport

MRI-negative ischemia and stroke mimics represent a significant source of diagnostic uncertainty in acute ischemic stroke care.

studysupported

Vertigo is a common stroke mimic leading to diagnostic uncertainty in the emergency setting.

studysupported

✦ Research metadata ✦

PMID: 42128969
DOI: 10.1007/s00415-026-13845-7.
Journal: Journal of Neurology
Publication type: research_article
Evidence level: 4
Population: Patients treated with thrombolysis for suspected acute ischemic stroke, including those with MRI-negative ischemia and stroke mimics
Intervention: Thrombolysis (intravenous tissue plasminogen activator) in suspected acute ischemic stroke
Comparator: Confirmed ischemic stroke cases

Primary outcomes

Clinical profiles of MRI-negative ischemia; Clinical profiles of stroke mimics post-thrombolysis; Rates of diagnostic uncertainty

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