1

Consider the psychological symptoms that are different in anxiety attacks and strokes. Anxiety attacks are usually accompanied by extreme fear and a sense of impending doom, while stroke symptoms usually carry no similar traits or characteristics.

2

Look at the unique characteristics of stroke that are not typically seen in panic or anxiety attacks. According to the Mayo Clinic, one major symptom that is unique to strokes is paralysis or numbing that is experienced on one side of the body. This is common in both heart attacks and strokes.

3

Review the major symptoms of each anxiety attack and stroke as a whole to distinguish the difference between the two. When looking at signs of a stroke, notice that the major symptoms relate to disabilities in motor skills. According to the Mayo Clinic, some of these major motor skill symptoms include difficulty with walking, speaking, and seeing.

On the other hand, HealthyPlace reports that major anxiety attack symptoms include nausea, feelings of unreality or losing control, sweating, faintness, and hot or cold flashes. Although these symptoms may cause trouble with motor skills, a stroke will usually bring on more severe motor skills difficulty.

I recently evaluated a young woman admitted to ED for suspected ischemic stroke, for whom conversion disorder was a consistent hypothesis.The kind of her unilateral motor (inconstant) and sensory defect (with a stricly median line), together with previous anxiety symptoms, and absence of vascular risk factors, were in my opinion indicators of probable psychogenic origin. NIHSS was low (6), so that I decided not to give rtPA. CT scan remained normal, so as echodoppler carotid sonography, and the day after her deficts were absent.

In most cases, it is simply because of the discrepancy or inconsistency of symptoms and signs with the respective anatomy, in other cases this is very difficult and only an MRI, particularly diffusion / perfusion will make clear.

One of the usual signs in conversive pseudo-paresis, is the fall of the hand without pronation. although most of the pictures conversive often difficult to interpret are sensory only.

http://Validity of the "Drift Without Pronation" Sign in Conversion Disorder.BMC Neurol. 2013;13(31)

Sometimes, despite everything, it's still difficult to tell the difference.

In my experience of giving hundreds of doses of tPA, I have been fooled a few times,

both ways. If there is time, an MRI with DWI can help.

Great. Thank you all for your insight. It helps gain perspective. Certainly as focus now exclusively in my current role, on strokes in the acute setting, I realize there is certainly more to know than we knew the 30+ years ago when I began my journey in this profession.

Thank you again for your time and responses.

Another way to distinguish true paralysis from psychogenic pseudoparesis is to let the patient's paralyzed limb fall frrely over the patient,s face. In pseudoparalysis it will always fall to the patient's side, avoiding the face; in true paralysis it would hit the face, so you may want to place your hand underneath to avoid injury to the patient. If the leg is weak, place your hand under the heel of the other leg. If you feel pressure on your hand while the patient attempts to raise the leg it is true weakness. If not, it is psychogenic. I hope this helps.

I think that your question is very important. From practical point of view I agree with the others that lessons are learnt both ways ie thrombolysing mimics and defering treatment in genuine strokes. The truth is that the risk of lysis in a mimic patient is low due to most often lack of risk factors for lysis-related bleeding (age >80, diabetes, CT changes etc...). The pivotal NINDS tPA trial had very simple inclusion criteria in comparison to our current practices and we may assume that a few mimics were also thrombolysed within it.

I attended a seminar on the latest developments in research in AD at which Dr Sarah Pendlebury of the NIHR Oxford Bomedical Research Centre made a presentatuion on "Stroke, Delirium, Neurodegeneration and Cogntitve Outcomes". I summarised all the presentations and below is my summary of her talk.

"Dr Pendlebury described her research in an Emergency Admission Unit in which she follows up elderly patients who become temporarily confused or delirious following a stroke. Originally studying the treatment of stroke and the subsequent health of stroke victims D Pendlebury’s Group has identified the occurrence of confusion or delirium in stroke victims to be an indicator of increased risk of the later development of dementia.

As many as 40% of showing signs of confusion or delirium subsequently contracted dementia, even when MRI brain scans showed no evidence at the time of the stroke of the protein tangles that characterize Alzheimer’s and other forms of dementia. She suggested that stroke victims exhibiting confusions and delirium should be considered as of high risk of later developing dementia."