How to approach a patient suspected of malingering a cerebrovascular accident (CVA) or stroke?

Approaching a Patient Suspected of Malingering Stroke

When a patient presents with suspected stroke symptoms that appear inconsistent or fabricated, you must still treat them as a true stroke until proven otherwise through objective diagnostic testing, as the consequences of missing a real stroke far outweigh the inconvenience of evaluating a stroke mimic. 1, 2

Initial Management Protocol

Treat as Real Until Proven Otherwise

• Activate the stroke protocol immediately regardless of suspicion for malingering, as approximately 30% of patients evaluated by stroke teams have stroke mimics, and clinical judgment alone is insufficient to exclude cerebrovascular events 3
• Perform rapid triage using validated stroke assessment tools (FAST: Face, Arm, Speech, Time) within 10 minutes of arrival, as these objective measures help distinguish true neurological deficits from inconsistent presentations 1, 2
• Obtain brain imaging (non-contrast CT or MRI) within 30 minutes of hospital arrival, as this is the only definitive way to differentiate ischemic stroke, hemorrhagic stroke, or stroke mimics 1, 4

Key Clinical Red Flags for Stroke Mimics

Look for these specific inconsistencies that suggest malingering or functional neurological disorder:

• Symptom resolution or fluctuation during examination is strongly associated with stroke mimics rather than true cerebrovascular events 5
• Nonspecific symptoms including isolated dizziness, nausea/vomiting, or altered mental status without focal neurological signs favor stroke mimics 5
• FAST-negative presentations (no facial droop, arm drift, or speech abnormality) despite patient reporting stroke symptoms are more commonly associated with mimics 5
• Inconsistent examination findings that violate neuroanatomical patterns or change dramatically between assessments suggest functional etiology 3, 5

Objective Diagnostic Workup

Complete the following mandatory investigations before dismissing stroke:

• Brain CT or MRI to exclude ischemic or hemorrhagic stroke, as clinical features alone have inadequate sensitivity and specificity 1, 4
• CT angiography or MR angiography from aortic arch to vertex within 24 hours to evaluate for vascular occlusion 1
• 12-lead ECG to identify arrhythmias like atrial fibrillation that could cause embolic stroke 1
• Laboratory tests including complete blood count, electrolytes, glucose, renal function, coagulation studies (PT/INR, aPTT), and troponin 1, 2
• Check blood glucose immediately to exclude hypoglycemia, which is a common stroke mimic that can present with focal neurological symptoms 1, 2

High-Risk Populations for Stroke Mimics

Be aware that certain patient characteristics increase the likelihood of stroke mimics:

• Younger patients without traditional vascular risk factors (hypertension, atrial fibrillation, hyperlipidemia, diabetes) have significantly higher odds of stroke mimics 3
• Women have a marginally higher proportion of stroke mimics compared to men 3
• Patients arriving by personal vehicle rather than EMS, or those who develop symptoms while already hospitalized, are more likely to have mimics 3
• Patients without any documented cerebrovascular risk factors have the greatest odds of having a stroke mimic 3

Common Stroke Mimic Diagnoses

After imaging excludes stroke, consider these alternative diagnoses:

• Seizures with post-ictal Todd's paralysis presenting as focal weakness 1
• Hypoglycemia or other metabolic derangements (electrolyte abnormalities, hepatic encephalopathy) 1
• Complicated migraine with aura causing transient focal neurological symptoms 1
• Functional neurological disorder (conversion disorder) with inconsistent examination findings 3, 5
• Brain tumors or subdural hematoma causing progressive focal deficits 1
• Toxic ingestions or medication effects 1

Critical Pitfalls to Avoid

Never make these dangerous assumptions:

• Do not withhold acute stroke imaging or delay CT scan based solely on clinical suspicion of malingering, as 22% of true strokes are initially FAST-negative and can be misdiagnosed 5
• Do not administer thrombolytic therapy or antiplatelet agents until hemorrhagic stroke is definitively excluded by imaging, regardless of how convincing the clinical presentation appears 1, 4
• Do not assume stroke type based on severity alone, as there is substantial overlap between hemorrhagic and ischemic presentations 4
• Do not dismiss posterior circulation strokes, which account for 39% of misdiagnosed strokes and often present with nonspecific symptoms like isolated dizziness, vertigo, or altered mental status without classic FAST findings 5
• Do not lower triage priority based on atypical presentation, as misdiagnosed patients are more commonly triaged to lower ED categories (62% vs 42%) and experience worse outcomes including increased mortality 5

Documentation and Disposition

After completing the diagnostic workup:

• If imaging and laboratory studies are normal and symptoms resolve or remain inconsistent with neuroanatomical patterns, document specific examination inconsistencies objectively 3, 5
• Consider neurology or psychiatry consultation for patients with recurrent presentations or clear functional neurological disorder 3
• Provide appropriate follow-up for identified alternative diagnoses (seizure disorder, migraine, metabolic conditions) 1
• Never document suspicion of malingering until all objective testing is complete and alternative diagnoses are thoroughly evaluated, as premature labeling can lead to catastrophic missed diagnoses in future presentations 5