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.

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.

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.

1. 01Retrospective study examining patients treated with thrombolysis who turned out not to have ischemic stroke (stroke mimics).
2. 02Vertigo is identified as a common presenting symptom in stroke mimic cases, creating diagnostic uncertainty.
3. 03MRI-negative ischemia represents a distinct diagnostic challenge separate from stroke mimics.
4. 04Highlights patient safety risks of both over- and under-treatment with thrombolysis in ambiguous cases.
5. 05Vestibular testing expertise (e.g., HINTS exam) may be critical in preventing misdiagnosis in these settings.

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