Optic nerve sheath diameter to diagnose psychogenic stroke

Background: Differential diagnosis between acute ischemic stroke and stroke mimics is important for initiating appropriate treatment. This study aimed to evaluate the diagnostic utility of optic nerve sheath diameter (ONSD) measured via cranial computed tomography (CT) for differentiating acute ischemic stroke from psychogenic stroke mimics in patients presenting to the emergency department (ED). Methods: This was a single-center, retrospective, case–control study. Patients were divided into two groups: patients with a definitive diagnosis of cerebrovascular accident (CVA) (Group 1, n = 612) and patients with psychogenic stroke-mimicking diseases (Group 2, n = 38). ONSD was measured using the initial brain CT scan performed upon admission to the ED. Results: The mean ONSD was 5.21 ± 0.71 mm in the overall population, and it was significantly higher in the acute CVA group (5.24 ± 0.73 mm) than in the psychogenic mimic group (4.32 ± 0.28 mm) (p < 0.001). In the receiver operating characteristics curve analysis conducted to assess the value of ONSD sufficient in distinguishing acute CVA from psychogenic stroke mimics, a cutoff of 4.87 mm yielded a sensitivity of 68.2% and a specificity of 95.5% (Area under the curve (AUC) = 0.885; 95% confidence interval (CI) = 0.838–0.932; p < 0.001). Conclusions: In patients presenting to the ED with suspected acute stroke, if ONSD is normal on brain CT, a more detailed history, neuropsychiatric examination and advanced neuroimaging should be performed before considering thrombolytic therapy to rule out the possibility of psychogenic stroke mimics.