Stroke Mimicker 1io55
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Stroke mimicker and
Unusual cause of stroke Surat Tanprawate, MD, MSc(London), FR(T) Division of Neurology, Chiangmai University Wednesday, March 21, 2012
Stroke Cerebrovascular accident Cerebrovascular disease Wednesday, March 21, 2012
1.When the time is brain... rt-PA is a good choice
Since 1995 rt-PA era
Wednesday, March 21, 2012
Sudden onset of neurological deficit
3 hrs->4.5 hrs->6 hrs->12 hrs
Wednesday, March 21, 2012
But...
Stroke “mimics,” non-vascular conditions that simulate stroke
Stroke. 2009;40:1522-1525
250 rt-PA treated patients, 243 (97.2%) had strokes and
7 (2.8%) were mimics (and was received rt-PA Donʼt forget that rt-PA increase risk of hemorrhage 6% Wednesday, March 21, 2012
Stroke mimicker • Stroke mimic is the term employed for
manifestations of nonvascular disease processes when a stroke-like clinical picture is produced
• The mimics include both processes
occurring within the CNS and systemic events
Wednesday, March 21, 2012
•
800 consecutive patients itted to a stroke unit from the emergency department of a Canadian hospital
•
They found the initial diagnosis of stroke incorrect in 13% of patients Ay H et al. Neurology. 1999;52:1784-1792.
Wednesday, March 21, 2012
Condition that mimic stroke miscellaneous SAH TGA vertigo MS syncope/presyncope
3.1%
dementia psychogenic migraine confusional state
3.6%
SDH tumour PN palsy toxic/metabolic
18.2%
seizures 0.0%
5.0%
10.0%
15.0%
20.0%
% of all stroke mimics (n=670)
Wednesday, March 21, 2012
25.0%
30.0%
Seizure and Toddʼs paralysis Robert Benley Todd (1809-1860) Irish-born London physiologist
Exhausted seizure brain Wednesday, March 21, 2012
•
Toddʼs paresis (post-ictal paralysis) is focal weakness in a part of the body after a seizure
•
Common in generalized tonic clonic seizure, or partial seizure
•
occur in 13% of the seizure patient
•
recovery within 36 hours
Variant of Toddʼs paralysis
• Postictal apraxia and prolonged postictal hemineglect
Helmchen C, Steinhoff BJ, Dichgans M. Nervenarzt 1994 Oct;65(10):700-3.
• Bilateral Todd's paralysis after focal seizures
Bergen DC, Rayman L, Heydemann P. Epilepsia. 1992 Nov-Dec;33(6):1101-5
• Mute postseizure patient: an unusual
manifestation of Todd's phenomenon. LaCapra S, King C. Ann Emerg Med. 1994 Apr;23 (4):877-80.
Wednesday, March 21, 2012
Post-stroke seizure or Toddʼs paralysis •
Stroke can produce seizures
• • •
embolus
Some clinical clues to differentiate both
• • • • Wednesday, March 21, 2012
intracranial hemorrhage
what come first; weak or seizure type of neurological deficit recovery imaging
Be aware: imaging in post-ictal encephalopathy In patient with status epilepticus; the imaging may change
An MRI brain of a Thai woman with status epilepticus, with no evidence of other cause of encephalopathy, showed temporal lobe lesion Wednesday, March 21, 2012
Migraine-the great mimicker
Wednesday, March 21, 2012
Aura alone Uncommon aura: dysphasia, weakness, vertigo, coma
Prolong aura: more than 60 minute Wednesday, March 21, 2012
Migraine Aura
Typical aura: -Visual -Sensory -Speech
99% 31%
6%
18%
n=163 Michael B. R. et al. Brain 1996: 119, 355-361 Wednesday, March 21, 2012
Migraine aura vs TIA Feature
Migraine
TIA
onset
progressive
sudden
progressive rate
slow
non
different symptoms
in succession
simultaneous
type of visual symptoms
negative or positive
negative
territory
cortical
vascular
duration
long (30-60 min)
short (10-15 min)
Jean Schoenen and Peter S Sándor. Lancet Neurol 2004; 3: 237–45 Wednesday, March 21, 2012
Can migraine induce infarct? Migraine with aura (MA)
•
Double stroke risk: women, < 45 years, smoker, oral contraceptive pill used
•
associated with subclinical WMLs
•
migrainous infarct
WMLs in migraine brain
T2-weight MRI show upper pons lesion in migrainous infarct Kruit MC, et al. Cephalalgia 2010 30: 129 Lee H, Whitman GT et al. Arch Neurol. 2003;60:113-116
Wednesday, March 21, 2012
Hemiplegic migraine Description
• Migraine with aura including motor weakness “Familial Hemiplegic Migraine (FHM)”
• at least one first- or second- degree
relative has migraine aura including motor weakness
“Sporadic Hemiplegic Migraine (SHM)”
• no first- or second-degree relative has aura including motor weakness
Wednesday, March 21, 2012
Tumor and stroke-like
H98IPPOKRATIA 2008, 12, 2: 98-102
Wednesday, March 21, 2012
Tumor and stroke like •
6% of brain tumor patients had symptoms that were of less than one dayʼs duration (at the Emergency department)
•
acute onset of tumor could be...
• • •
Wednesday, March 21, 2012
hemorrhage into tumor obstructive hydrocephalus secondary effect from of mass or edema on cerebral vasculature
Toxic/Metabolic-??? Hypoglycemia and focal paresis -a case description
Wednesday, March 21, 2012
Wednesday, March 21, 2012
Functional hemiparesis • Conversion disorder is the most
commonly assigned psychiatric disorder
• One study of emergency department
presentations of conversion disorder noted that symptoms of paresis, paralysis, or movement disorders were common and were a presentation in almost 30% of patients.
Wednesday, March 21, 2012
Hooverʼs sign: testing functional weakness J Stone, A Carson, M Sharpe J Neurol Neurosurg Psychiatry 2005;76:i2-i12
Wednesday, March 21, 2012
functional sensory disturbance
functional gait disorder
J Stone, A Carson, M Sharpe J Neurol Neurosurg Psychiatry 2005;76:i2-i12 Wednesday, March 21, 2012
2. The clinical suggesting stroke is abrupt onset of neurological deficit
Point... “Not all stroke patient come with sudden neurological deficit” Strokes with atypical presentations that take on the appearance of other disease process
“stroke cameleons”
Wednesday, March 21, 2012
Stroke chameleons •
what is common...hemiparesis, sensory loss, ataxia, language disorder, visual loss, vertigo
•
what is uncommon...
Wednesday, March 21, 2012
•
uncommon manifestation: movement disorder, behavior abnormality, pain, isolated memory loss.. etc
•
uncommon time-course...slow progressive, fluctuation
3. the major cause of stroke is atherosclerosis
Cardiac embolism
Atherosclerosis Wednesday, March 21, 2012
Stroke can be... Ischemic 75%
Hemorrhagic (25%); subarachnoid, intracerebral
HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41
Wednesday, March 21, 2012
TOAST classification •
Large-artery atherosclerosis(emboli/ thrombosis)
•
Cardioembolism(high-risk/mediumrisk)
• • •
Small-vessel occlusion(lacune) Stroke of other determine etiology Stroke of undetermined etiology
TOAST, Trial of Org 10172 in Acute Stroke Treatment.
Uncommon cause of stroke... the non-atherosclerotic stroke • •
Dissection Inflammatory vasculopathy
• • •
Trauma
•
Inherit disorder
Wednesday, March 21, 2012
Moyamoya Radiation vasculopathy
• • •
Infection and stroke
• •
migraine and stroke
•
Hypercoagulable state
Drug abuse and stroke Stroke and systemic vasculitis
Fibromuscular dysplasia
Clinical clues • Stroke in the young • No atherosclerotic risk • Underlying of particular disease; SLE, AIDS, carcinoma, migraine
• Atypical presentation • Fail to conventional treatment Wednesday, March 21, 2012
Causes of Infarction in 100 Young Adults RG Hart and VT Miller Stroke 1983, 14:110-114
Wednesday, March 21, 2012
How to make a stroke diagnosis?
RG Hart and VT Miller Stroke 1983, 14:110-114
Wednesday, March 21, 2012
Show case
Wednesday, March 21, 2012
58 Y.O. man presented with dizziness, and become coma
Basilar artery thrombosis Wednesday, March 21, 2012
Basilar artery supply the brain stem
Reticular activating system(RAS) control conscious Wednesday, March 21, 2012
55 Y.O. woman presented with subacute headache and then weakness of right arm CT Brain non-contrast filling hyperdense along superior sagittal sinus Dx. Superior sagittal vein thrombosis
Wednesday, March 21, 2012
F/U Hemorrhage in venous infarct
Wednesday, March 21, 2012
Clinical clues for venous stroke •
headache before stroke onset: progressive headache, thunderclap headache, cough headache
• •
more likely to present with seizure distribution of stroke
• • • • • Wednesday, March 21, 2012
may be uni-or bilateral not distribute along artery territory may associated with hemorrhage tend to be subcortical clot along venous system
59 Y.O. man presented with acute left-right confusion
Underlying
Cholangio carcinoma Dx. stroke due to
Infarction of right parietal lobe Wednesday, March 21, 2012
hypercoagulable state
A 41 Y.O. woman presented with proximal muscle weakness and generalized hyperreflexia
Dx. Watershed infarction due to bilateral carotid artery stenosis Wednesday, March 21, 2012
Watershed or Border zone infarct Normal Border zone ischemia Ischemia at center of blood supply
Anterior watershed Subcortical watershed Posterior watershed Wednesday, March 21, 2012
Man in the Barrel Watershed infarction -anterior -posterior
Wednesday, March 21, 2012
A 24 Y.O. Thai lady presented was itted to the hospital because of an acute left arm and leg weakness for 1 day Underlying SLE Dx. multiple intracranial hemorrhage
Wednesday, March 21, 2012
Angiogram: “Beat like pattern”
Dx. Intracranial hemorrhage due to CNS vasculitis Wednesday, March 21, 2012
Other cause
Wednesday, March 21, 2012
Carotid dissection and stroke ■ Cause: ■ spontaneous ■ traumatic The signs and symptoms of carotid artery dissection may be divided into ischemic and non-ischaemic categories: Non-ischaemic signs and symptoms ■ Headache or neck pain Ischaemic signs and symptoms ■ Decreased pupil size with drooping of the upper eyelid (Hornerʼs syndrome) ■ Transient vision loss ■ Ischemic stroke Wednesday, March 21, 2012
String sign
Cause of carotid dissection
S. Micheli The Open Neurology Journal, 2010, 4, 50-55
Wednesday, March 21, 2012
Stroke in HIV infection
etiology
Stroke in HIV includes - infectious -HIV vasculitides -coagulopathy -cardioembolism
J Neurol Neurosurg Psychiatry. 2007; 78(12): 1320–1324.
Wednesday, March 21, 2012
HIV vasculopathy
Computed tomography cerebral angiography demonstrating multifocal stenoses (arrows) of the left middle cerebral artery (MCA) in a HIV positive patient with stroke.
John W. Cole. Stroke. 2004; 35: 51-56
Digital subtraction angiogram demonstrating fusiform dilatation of the right second portion of the posterior cerebral artery
Wednesday, March 21, 2012
Wednesday, March 21, 2012
slide at... openneurons
Wednesday, March 21, 2012
Unusual cause of stroke Surat Tanprawate, MD, MSc(London), FR(T) Division of Neurology, Chiangmai University Wednesday, March 21, 2012
Stroke Cerebrovascular accident Cerebrovascular disease Wednesday, March 21, 2012
1.When the time is brain... rt-PA is a good choice
Since 1995 rt-PA era
Wednesday, March 21, 2012
Sudden onset of neurological deficit
3 hrs->4.5 hrs->6 hrs->12 hrs
Wednesday, March 21, 2012
But...
Stroke “mimics,” non-vascular conditions that simulate stroke
Stroke. 2009;40:1522-1525
250 rt-PA treated patients, 243 (97.2%) had strokes and
7 (2.8%) were mimics (and was received rt-PA Donʼt forget that rt-PA increase risk of hemorrhage 6% Wednesday, March 21, 2012
Stroke mimicker • Stroke mimic is the term employed for
manifestations of nonvascular disease processes when a stroke-like clinical picture is produced
• The mimics include both processes
occurring within the CNS and systemic events
Wednesday, March 21, 2012
•
800 consecutive patients itted to a stroke unit from the emergency department of a Canadian hospital
•
They found the initial diagnosis of stroke incorrect in 13% of patients Ay H et al. Neurology. 1999;52:1784-1792.
Wednesday, March 21, 2012
Condition that mimic stroke miscellaneous SAH TGA vertigo MS syncope/presyncope
3.1%
dementia psychogenic migraine confusional state
3.6%
SDH tumour PN palsy toxic/metabolic
18.2%
seizures 0.0%
5.0%
10.0%
15.0%
20.0%
% of all stroke mimics (n=670)
Wednesday, March 21, 2012
25.0%
30.0%
Seizure and Toddʼs paralysis Robert Benley Todd (1809-1860) Irish-born London physiologist
Exhausted seizure brain Wednesday, March 21, 2012
•
Toddʼs paresis (post-ictal paralysis) is focal weakness in a part of the body after a seizure
•
Common in generalized tonic clonic seizure, or partial seizure
•
occur in 13% of the seizure patient
•
recovery within 36 hours
Variant of Toddʼs paralysis
• Postictal apraxia and prolonged postictal hemineglect
Helmchen C, Steinhoff BJ, Dichgans M. Nervenarzt 1994 Oct;65(10):700-3.
• Bilateral Todd's paralysis after focal seizures
Bergen DC, Rayman L, Heydemann P. Epilepsia. 1992 Nov-Dec;33(6):1101-5
• Mute postseizure patient: an unusual
manifestation of Todd's phenomenon. LaCapra S, King C. Ann Emerg Med. 1994 Apr;23 (4):877-80.
Wednesday, March 21, 2012
Post-stroke seizure or Toddʼs paralysis •
Stroke can produce seizures
• • •
embolus
Some clinical clues to differentiate both
• • • • Wednesday, March 21, 2012
intracranial hemorrhage
what come first; weak or seizure type of neurological deficit recovery imaging
Be aware: imaging in post-ictal encephalopathy In patient with status epilepticus; the imaging may change
An MRI brain of a Thai woman with status epilepticus, with no evidence of other cause of encephalopathy, showed temporal lobe lesion Wednesday, March 21, 2012
Migraine-the great mimicker
Wednesday, March 21, 2012
Aura alone Uncommon aura: dysphasia, weakness, vertigo, coma
Prolong aura: more than 60 minute Wednesday, March 21, 2012
Migraine Aura
Typical aura: -Visual -Sensory -Speech
99% 31%
6%
18%
n=163 Michael B. R. et al. Brain 1996: 119, 355-361 Wednesday, March 21, 2012
Migraine aura vs TIA Feature
Migraine
TIA
onset
progressive
sudden
progressive rate
slow
non
different symptoms
in succession
simultaneous
type of visual symptoms
negative or positive
negative
territory
cortical
vascular
duration
long (30-60 min)
short (10-15 min)
Jean Schoenen and Peter S Sándor. Lancet Neurol 2004; 3: 237–45 Wednesday, March 21, 2012
Can migraine induce infarct? Migraine with aura (MA)
•
Double stroke risk: women, < 45 years, smoker, oral contraceptive pill used
•
associated with subclinical WMLs
•
migrainous infarct
WMLs in migraine brain
T2-weight MRI show upper pons lesion in migrainous infarct Kruit MC, et al. Cephalalgia 2010 30: 129 Lee H, Whitman GT et al. Arch Neurol. 2003;60:113-116
Wednesday, March 21, 2012
Hemiplegic migraine Description
• Migraine with aura including motor weakness “Familial Hemiplegic Migraine (FHM)”
• at least one first- or second- degree
relative has migraine aura including motor weakness
“Sporadic Hemiplegic Migraine (SHM)”
• no first- or second-degree relative has aura including motor weakness
Wednesday, March 21, 2012
Tumor and stroke-like
H98IPPOKRATIA 2008, 12, 2: 98-102
Wednesday, March 21, 2012
Tumor and stroke like •
6% of brain tumor patients had symptoms that were of less than one dayʼs duration (at the Emergency department)
•
acute onset of tumor could be...
• • •
Wednesday, March 21, 2012
hemorrhage into tumor obstructive hydrocephalus secondary effect from of mass or edema on cerebral vasculature
Toxic/Metabolic-??? Hypoglycemia and focal paresis -a case description
Wednesday, March 21, 2012
Wednesday, March 21, 2012
Functional hemiparesis • Conversion disorder is the most
commonly assigned psychiatric disorder
• One study of emergency department
presentations of conversion disorder noted that symptoms of paresis, paralysis, or movement disorders were common and were a presentation in almost 30% of patients.
Wednesday, March 21, 2012
Hooverʼs sign: testing functional weakness J Stone, A Carson, M Sharpe J Neurol Neurosurg Psychiatry 2005;76:i2-i12
Wednesday, March 21, 2012
functional sensory disturbance
functional gait disorder
J Stone, A Carson, M Sharpe J Neurol Neurosurg Psychiatry 2005;76:i2-i12 Wednesday, March 21, 2012
2. The clinical suggesting stroke is abrupt onset of neurological deficit
Point... “Not all stroke patient come with sudden neurological deficit” Strokes with atypical presentations that take on the appearance of other disease process
“stroke cameleons”
Wednesday, March 21, 2012
Stroke chameleons •
what is common...hemiparesis, sensory loss, ataxia, language disorder, visual loss, vertigo
•
what is uncommon...
Wednesday, March 21, 2012
•
uncommon manifestation: movement disorder, behavior abnormality, pain, isolated memory loss.. etc
•
uncommon time-course...slow progressive, fluctuation
3. the major cause of stroke is atherosclerosis
Cardiac embolism
Atherosclerosis Wednesday, March 21, 2012
Stroke can be... Ischemic 75%
Hemorrhagic (25%); subarachnoid, intracerebral
HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41
Wednesday, March 21, 2012
TOAST classification •
Large-artery atherosclerosis(emboli/ thrombosis)
•
Cardioembolism(high-risk/mediumrisk)
• • •
Small-vessel occlusion(lacune) Stroke of other determine etiology Stroke of undetermined etiology
TOAST, Trial of Org 10172 in Acute Stroke Treatment.
Uncommon cause of stroke... the non-atherosclerotic stroke • •
Dissection Inflammatory vasculopathy
• • •
Trauma
•
Inherit disorder
Wednesday, March 21, 2012
Moyamoya Radiation vasculopathy
• • •
Infection and stroke
• •
migraine and stroke
•
Hypercoagulable state
Drug abuse and stroke Stroke and systemic vasculitis
Fibromuscular dysplasia
Clinical clues • Stroke in the young • No atherosclerotic risk • Underlying of particular disease; SLE, AIDS, carcinoma, migraine
• Atypical presentation • Fail to conventional treatment Wednesday, March 21, 2012
Causes of Infarction in 100 Young Adults RG Hart and VT Miller Stroke 1983, 14:110-114
Wednesday, March 21, 2012
How to make a stroke diagnosis?
RG Hart and VT Miller Stroke 1983, 14:110-114
Wednesday, March 21, 2012
Show case
Wednesday, March 21, 2012
58 Y.O. man presented with dizziness, and become coma
Basilar artery thrombosis Wednesday, March 21, 2012
Basilar artery supply the brain stem
Reticular activating system(RAS) control conscious Wednesday, March 21, 2012
55 Y.O. woman presented with subacute headache and then weakness of right arm CT Brain non-contrast filling hyperdense along superior sagittal sinus Dx. Superior sagittal vein thrombosis
Wednesday, March 21, 2012
F/U Hemorrhage in venous infarct
Wednesday, March 21, 2012
Clinical clues for venous stroke •
headache before stroke onset: progressive headache, thunderclap headache, cough headache
• •
more likely to present with seizure distribution of stroke
• • • • • Wednesday, March 21, 2012
may be uni-or bilateral not distribute along artery territory may associated with hemorrhage tend to be subcortical clot along venous system
59 Y.O. man presented with acute left-right confusion
Underlying
Cholangio carcinoma Dx. stroke due to
Infarction of right parietal lobe Wednesday, March 21, 2012
hypercoagulable state
A 41 Y.O. woman presented with proximal muscle weakness and generalized hyperreflexia
Dx. Watershed infarction due to bilateral carotid artery stenosis Wednesday, March 21, 2012
Watershed or Border zone infarct Normal Border zone ischemia Ischemia at center of blood supply
Anterior watershed Subcortical watershed Posterior watershed Wednesday, March 21, 2012
Man in the Barrel Watershed infarction -anterior -posterior
Wednesday, March 21, 2012
A 24 Y.O. Thai lady presented was itted to the hospital because of an acute left arm and leg weakness for 1 day Underlying SLE Dx. multiple intracranial hemorrhage
Wednesday, March 21, 2012
Angiogram: “Beat like pattern”
Dx. Intracranial hemorrhage due to CNS vasculitis Wednesday, March 21, 2012
Other cause
Wednesday, March 21, 2012
Carotid dissection and stroke ■ Cause: ■ spontaneous ■ traumatic The signs and symptoms of carotid artery dissection may be divided into ischemic and non-ischaemic categories: Non-ischaemic signs and symptoms ■ Headache or neck pain Ischaemic signs and symptoms ■ Decreased pupil size with drooping of the upper eyelid (Hornerʼs syndrome) ■ Transient vision loss ■ Ischemic stroke Wednesday, March 21, 2012
String sign
Cause of carotid dissection
S. Micheli The Open Neurology Journal, 2010, 4, 50-55
Wednesday, March 21, 2012
Stroke in HIV infection
etiology
Stroke in HIV includes - infectious -HIV vasculitides -coagulopathy -cardioembolism
J Neurol Neurosurg Psychiatry. 2007; 78(12): 1320–1324.
Wednesday, March 21, 2012
HIV vasculopathy
Computed tomography cerebral angiography demonstrating multifocal stenoses (arrows) of the left middle cerebral artery (MCA) in a HIV positive patient with stroke.
John W. Cole. Stroke. 2004; 35: 51-56
Digital subtraction angiogram demonstrating fusiform dilatation of the right second portion of the posterior cerebral artery
Wednesday, March 21, 2012
Wednesday, March 21, 2012
slide at... openneurons
Wednesday, March 21, 2012
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