Stroke Mimics in the AMU. Dr Joe Harbison St James s Hospital & Trinity College Dublin
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1 Stroke Mimics in the AMU Dr Joe Harbison St James s Hospital & Trinity College Dublin
2 My inspiration
3 48 year old male. Admitted to AMU with dysphasia and dysarthria.? Onset on waking NIHSS 3 No motor loss, no other cortical signs Only obvious risk, smokes 30 /day Urgent CT Normal Sent to another hospital for MRB: Result pending
4
5 Doppler carotids L ICA stenosis 80% Speech problems persist. Scheduled for Endarterectomy. MR report arrives: Normal CT angio reviewed 50% stenosis.
6
7 Questions. Is it a stroke or a stroke mimic? What do we do next? Do we operate on him tomorrow?
8 What is a stroke mimic? Patients presenting with symptoms mistakenly thought to be due to stroke on initial assessment. Assessment by who? How early in the diagnostic process?
9 Non-strokes. About 15-20% of strokes are not. >50% of TIAs are not. Acute onset focal neurological deficit of vascular origin. Remember the ROSIER Scale.
10
11 Causes Hand et al Stroke 2006
12
13 Thrombolysed Mimics Winkler et al Stroke 2009
14 Neurology 2010;74:
15
16 Vroomen et al JSCVD 2008 Stroke mimics and age
17 * 2x3 Fishers exact test *p=0.003 Stroke Mimics and Source Harbison et al Stroke 2003
18 No ICD 10 classification for.. I can t completely explain the cause of your funny turn, but I m pretty sure it wasn t a TIA or Stroke. In any case, your secondary prevention therapy is fairly comprehensive and I don t think pursuing the episode with a bunch of scans would necessarily change things at the moment, but get back to me if you have another one and we ll think again.
19 Remembering a differential: Surprisingly succinct, simple strategy. Seizure Syncope Infection Tumours Metabolic Migraine Alcohol / Drugs Functional Subdurals Seizure Syncope Sepsis Space occupying lesions Sugar or salt Spasm of artery Substance misuse psychological Subdurals Social
20 The Sacred Disease. Partial Seizures. Todd s Paresis.
21 Partial Seizures Commonly young or middle aged adults. Following previous cortical stroke. May have antecedent symptoms. Onset seconds-minutes. Positive neurological symptoms. March of symptoms Resolution over few minutes. Amnesia for the event. Stereotypical attacks, reduce with antiepileptic treatment.
22 Robert Bentley Todd: 1849 Seizure
23 Todd s Paresis 15% of seizures. Most common after GTC especially after clonic activity. Usually causes a hemiparesis. Can cause aphasia, sensory loss or visual field defect (uncommonly) Usually lasts minutes but can last hours or even days.
24 But. 2% of patients have a seizure at stroke onset. TACS & PICH / SAH. 25% incidence in ICH/SAH. 5% patients will have a seizure within the first two weeks post stroke. Thrombolysis ICH; Up to 36 hours. EEG can be difficult to interpret.
25 Admitted in partial status
26 Migraine. Hemicrania Migraigne Migraine
27 Migraine Affect 25% women, 8% men. 25% Migraine with aura. 50% of US Neurologists > 80% of US female headache neurologists.
28 Migraine forms. Hemiplegic Migraine. Acephalgic Migraine. Benign recurrent vertigo. Prolonged Aura. Status migrainosus.
29 Hemiplegic Migraine First described in1893 by Living 4 subtypes (FHM 1-4) + sporadic forms. Ion channelopathies Migraine with aura with hemiplegic features, usually familial with one first degree relative with attacks. Hemiparesis may alternate from side to side minutes duration followed by severe headache Familial forms Autosomal Dominant FHM1: Ch 19p, FHM2: Ch1p, FHM3: Ch 2p, FHM4: Ch 1p
30 Migraine aura. Gradual Onset. Positive symptoms. Symptom spread over several seconds to minutes. Gradual resolution over minutes Headache Recurrent Stereotyped attacks. Typically young.
31 Migranous Stroke T2 FLAIR DWI B1000
32 Reversible Cerebral Vasoconstriction Syndrome.? One or a group of disorders Sudden Thunderclap headache. Cerebral vasoconstriction on MRA Brain Resolve in days-weeks. High (>50%) risk of stroke (14%, ICH). Can be managed by CCBs Beware in peurperium or pregnancy.
33 RCVS Calabrese et al: Annals Int Med Jan 2007
34 Consequences 5 th August 27 th September
35 Functional weaknesses. Unusual non-ergonomic gait. Inconsistent neurology. Pain at onset (be careful). Positive Hoover s sign (be very careful). History of previous episodes. Beware la belle indifference. Check plantars and fundi. Sensory, visual, or speech problems also occur.?when to stop investigating?
36 Ministry of silly walks.
37 Functional weaknesses. Not the same as malingering. Characteristic fmri changes (reduced activation). Software not a Hardware problem. Benefit from CBT, neuropsychiatric evaluation.
38 Functional weakness?
39 Amyloid angiopathy Doesn t appear on any differential. Multiple PICHs typically posterior. Dementia, Alzheimer s pattern. Stereotyped transient neurologic events. Focal weaknesses. Parasthesia. Focal Numbness. Can be precursor to large bleed.
40 Amyloid Angiopathy. Stereotyped transient neurologic events. Symptoms spread to contiguous body parts over 2-10 minutes. May involve areas in several vascular territories. Probably due to small cortical petechial hemorrhages that lead to focal seizures. The rate of spread similar to migraine?? Spreading depression of neuronal activity. Can present with transient confusion or episodes of visual misperceptions. Diagnosis T2* MRI (gradient echo)
41 Intermittent Dysphasia
42 Amyloid angiopathy T2* GRE
43 Hypertensive angiopathy
44 Stroke Mimics & Chameleons Posterior Reversible Encephalopathy Syndrome. 1 week post chemo 6 days later
45 Stroke Chameleons Strokes with positive symptoms. Limbic and orbitofrontal strokes. Subthalamic Nucleus stroke Thalamic stroke
46 Confusion post PTCA
47 Beware.. Some mimics also cause strokes, given the right circumstances.
48 Syncope.
49 Radiological Mimics
50 Radiological Mimics
51 MR Clearer.
52 Transient Right Hemi and Confusion
53 CT Following Syncope Virchow Robin Space
54 Conclusions Stroke Mimics are common and can be difficult to diagnose. Rarely stroke mimics can be causes of stroke. Occasionally stroke can present more like a mimic than a true stroke.
55 Repeat MR & MRA
56
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