Issue #706

Major Review of stroke mimics and chameleons
CTCA's may not help improve outcomes after ruling out MI
Case: A 78 yo with fever, bradycardia and shock
Kanavel's Signs of Tendon Sheath Infections

Stroke Mimics and Chameleons: Don't Be Fooled.

Not every patient who looks like they're having a stroke is having one. More importantly, not every patient having a stroke looks like they're having one.

Stroke mimics, including seizures, migraine, functional neurological disorders and metabolic disturbances, are common presentations in the emergency department.

But perhaps the greater danger is the stroke chameleon — a genuine stroke presenting with atypical symptoms such as isolated vertigo, gait instability, visual disturbance or confusion. These patients may be missed, delaying potentially life-saving treatment.

The 2026 AHA/ASA Stroke Guidelines make recognising these presentations even more important:

Tenecteplase or alteplase is recommended for eligible patients within 4.5 hours.
Disabling deficits matter more than NIHSS alone. A low NIHSS does not necessarily mean a minor stroke.
Extended treatment windows: Selected patients may receive imaging-guided thrombolysis beyond 4.5 hours or thrombectomy up to 24 hours.
Don't delay treatment unnecessarily while attempting to exclude every possible stroke mimic.

In this detailed review, I examine the common mimics, the dangerous chameleons, the limitations of early imaging and an approach to distinguishing them in the ED.

The greatest danger may not be treating someone who doesn't have a stroke — it may be failing to recognise someone who does.

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Does CT Coronary Angiography Improve Outcomes After MI Has Been Ruled Out?

The TARGET-CTCA Trial | NEJM 2026

We frequently discharge patients from the Emergency Department after ruling out acute myocardial infarction using high-sensitivity troponin testing. But should we be investigating these patients further with CT coronary angiography (CTCA)?

The TARGET-CTCA trial, published in the New England Journal of Medicine, randomised 3,170 patients with suspected acute coronary syndrome, in whom MI had been excluded but troponin concentrations suggested intermediate cardiovascular risk.

Patients received either early outpatient CTCA-guided management or standard care.

What did they find?

Despite identifying significant coronary artery disease and increasing the use of preventative medications, CTCA made no significant difference to subsequent myocardial infarction or cardiac death over three years.

CTCA group: 7.1%
Standard care: 7.3%
Hazard ratio: 0.95 (95% CI 0.73–1.23)

Interestingly, CTCA identified coronary artery disease in approximately two-thirds of those scanned, but this additional information did not translate into improved cardiovascular outcomes.

More testing does not necessarily mean better outcomes. Routine CTCA following exclusion of MI may not be necessary, even in patients with intermediate troponin concentrations.

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A 78 YO WITH FEVER, BRADYCARDIA AND SHOCK. PAST MEDICAL HISTORY INCLUDED AF AND HT

VIEW THE INSTAGRAM DIAGNOSTIC CHALLENGE

Flexor Tendon Sheath Infections: Don't Miss This Surgical Emergency

A swollen, painful finger following a seemingly minor penetrating injury may represent a flexor tendon sheath infection (pyogenic flexor tenosynovitis) — a potentially limb-threatening surgical emergency.

Infection can progress rapidly within the closed flexor tendon sheath, resulting in tendon necrosis and permanent loss of function.

The key to diagnosis is recognising Kanavel's four signs:

Finger held in slight flexion.
Fusiform (circumferential) swelling.
Tenderness along the flexor tendon sheath.
Severe pain on passive extension.

Importantly, all four signs are present in only approximately 50% of cases, so their absence does not exclude the diagnosis.

Normal inflammatory markers are also unreliable. A normal white cell count or CRP should not reassure us that an infection is absent.

The clinical takeaway: A swollen, infected finger that is painful to move should raise immediate suspicion of flexor tenosynovitis. Early recognition and urgent hand surgical assessment are essential to prevent devastating complications.

READ THE FULL REVIEW ON RESUS.COM.AU