Factitious stroke presenting for acute treatment.

Four patients who were ultimately determined to have factitious neurological deficits were initially assessed as meeting eligibility criteria for treatment with intravenous recombinant tissue plasminogen activator (IV rt-PA), or enrollment in an acute stroke study. Two patients presented within the 3-hour IV rt-PA window; two presented between 4 and 6 hours after symptom onset. Evaluation by the Stroke Team responsible for IV rt-PA treatment or clinical study enrollment determined that three patients met all eligibility criteria, except for a fluctuating or rapidly improving deficit; these patients did not receive rt-PA or study enrollment. One patient whose deficit did not fluctuate or improve on Stroke Team evaluation was enrolled in an acute stroke study. Compared with 36 nonfactitious patients who received IV rt-PA or study enrollment, factitious patients were less likely to have facial weakness, aphasia, neglect, or visual field deficit. Because criteria for IV rt-PA and many stroke studies do not currently require imaging of a vascular occlusion or ischemic brain tissue, patients with factitious stroke may appear to meet these eligibility criteria. Physicians experienced in acute stroke evaluation and management are most likely to identify patients with factitious stroke and exclude them from consideration for thrombolysis or stroke study enrollment.