With 50% mimic rates in prior studies, telestroke consultation may be able to provide an early, accurate diagnosis to patients with stroke mimics, thus avoiding unnecessary treatments and transfers. However, data are lacking on whether telestroke can accuarately diagnose patients with stroke versus stroke mimics. To investigate this accuracy, researchers conducted a retrospective review of 405 telestroke cases with diagnoses determined by the discharging physician and coded into 12 categories by two physicians. Among cases, 225 were diagnosed with acute ischemic stroke/transient ischemic attack (AIS/TIA), 45% of which received intravenous tissue plasminogen activator. The telestroke system had a diagnostic agreement for AIS/TIA of 88%, with a kappa of 0.75 for stroke and mimics. Among patients diagnosed with a stroke mimic via telestroke consultation, 15% were diagnosed with AIA/TIA by discharge. Telestroke has a positive predictive value (PPV) of 85% and a negative predictive value (NPV) of 90% for mimic diagnosis, with a PPV of 90% and NPV of 85% for stroke/TIA.