Stroke mimicker

and

Unusual cause of stroke
Surat Tanprawate, MD, MSc(London), FRCP(T) Division of Neurology, Chiangmai University
Saturday, May 11, 2013 1

Outline of my talk today
• Stroke Mimicker • Stroke cameleons • Unusual cause of stroke
Saturday, May 11, 2013 2

When the time is brain... rt-PA is a good choice

Since 1995
rt-PA era
Saturday, May 11, 2013 3

Sudden onset of neurological deficit

3 hrs->4.5 hrs->6 hrs->12 hrs

Saturday, May 11, 2013

4

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%
Saturday, May 11, 2013 5

Stroke mimicker • Stroke mimic is the term employed for • The mimics include both processes manifestations of nonvascular disease processes when a stroke-like clinical picture is produced occurring within the CNS and systemic events Saturday. May 11. 2013 6 .

1999.52:1784-1792. May 11. Saturday.• • 800 consecutive patients admitted 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. 2013 7 . Neurology.

6% 3.2% 3. May 11.0% 5.1% % of all stroke mimics (n=670) Saturday.0% 25.0% 18.0% 20.0% 15.0% 10. 2013 8 .Condition that mimic stroke miscellaneous SAH TGA vertigo MS syncope/presyncope dementia psychogenic migraine confusional state SDH tumour PN palsy toxic/metabolic seizures 0.0% 30.

or partial seizure occur in 13% of the seizure patient recovery within 36 hours Exhausted seizure brain Saturday. May 11. 2013 9 .Seizure and Toddʼs paralysis Robert Benley Todd (1809-1860) Irish-born London physiologist • • • • Toddʼs paresis (post-ictal paralysis) is focal weakness in a part of the body after a seizure Common in generalized tonic clonic seizure.

weak or seizure type of neurological deficit recovery imaging 10 . May 11. 2013 intracranial hemorrhage embolus Some clinical clues to differentiate both what come first.Post-stroke seizure or Toddʼs paralysis • • Stroke can produce seizures • • • • • • Saturday.

Migraine-the great mimicker Saturday. 2013 11 . May 11.

Aura alone Uncommon aura: dysphasia. coma Prolong aura: more than 60 minute Saturday. 2013 12 . May 11. vertigo. weakness.

Brain 1996: 119. 2013 13 . May 11.Migraine Aura 99% 31% Typical aura: -Visual -Sensory -Speech 6% 18% n=163 Michael B. 355-361 Saturday. et al. R.

or second-degree relative has aura including motor weakness Saturday.Hemiplegic migraine Description • Migraine with aura including motor weakness “Familial Hemiplegic Migraine (FHM)” • at least one first.or second. May 11. 2013 14 .degree “Sporadic Hemiplegic Migraine (SHM)” relative has migraine aura including motor weakness • no first.

May 11. 2013 15 .I was reported that a young aged man came into the hospital because transient weakness of his right side of the body Saturday.

Lancet Neurol 2004. May 11. 3: 237–45 Saturday.Migraine aura vs TIA Feature onset progressive rate different symptoms type of visual symptoms territory duration Migraine progressive slow in succession negative or positive cortical long (30-60 min) TIA sudden non simultaneous negative vascular short (10-15 min) Jean Schoenen and Peter S Sándor. 2013 16 .

Tumor and stroke-like H98IPPOKRATIA 2008. 12. 2: 98-102 Saturday. May 11. 2013 17 .

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. • • • hemorrhage into tumor obstructive hydrocephalus secondary effect from of mass or edema on cerebral vasculature Saturday. May 11... 2013 18 .

Toxic/Metabolic-??? Hypoglycemia and focal paresis -a case description Saturday. 2013 19 . May 11.

Saturday. 2013 20 . May 11.

2013 21 . paralysis. May 11.Functional hemiparesis • Conversion disorder is the most commonly assigned psychiatric disorder presentations of conversion disorder noted that symptoms of paresis. • One study of emergency department Saturday. or movement disorders were common and were a presentation in almost 30% of patients.

May 11.functional sensory disturbance functional gait disorder J Stone. M Sharpe J Neurol Neurosurg Psychiatry 2005. A Carson.76:i2-i12 Saturday. 2013 22 .

May 11. “Not all stroke patient come with sudden neurological deficit” Strokes  with  atypical  presentations   that  take  on  the  appearance  of   other  disease  process   “stroke  cameleons” Saturday. The clinical suggesting stroke is abrupt onset of neurological deficit Point..2. 2013 23 ..

. vertigo what is uncommon. 2013 uncommon manifestation: movement disorder.. behavior abnormality. language disorder.Stroke chameleons • • what is common.hemiparesis. isolated memory loss... ataxia.slow progressive. May 11.... visual loss. etc uncommon time-course. sensory loss. pain. fluctuation 24 . • • Saturday.

May 11.O.48 Y. 2013 25 . man with right side abnormal movement Saturday.

May 11.Saturday. 2013 26 .

the major cause of stroke is atherosclerosis Cardiac embolism Atherosclerosis Saturday. May 11. 2013 27 .

intracerebral • • • • HP Adams. Trial of Org 10172 in Acute Stroke Treatment. 2013 . Ischemic 75% TOAST classification • Large-artery atherosclerosis(emboli/ thrombosis) Cardioembolism(high-risk/mediumrisk) Small-vessel occlusion(lacune) Stroke of other determine etiology Stroke of undetermined etiology Hemorrhagic (25%). May 11. BH Bendixen.35-41 TOAST. subarachnoid.. Stroke 1993. Jr..Stroke can be. 28 Saturday.24.

. the non-atherosclerotic stroke • • • • • • Saturday.Uncommon cause of stroke. May 11.. 2013 Dissection Inflammatory vasculopathy Trauma Moyamoya Radiation vasculopathy Inherit disorder • • • • • • Infection and stroke Drug abuse and stroke Stroke and systemic vasculitis migraine and stroke Fibromuscular dysplasia Hypercoagulable state 29 .

carcinoma.Clinical clues • Stroke in the young • No atherosclerotic risk • Underlying of particular disease. May 11. migraine • Atypical presentation • Fail to conventional treatment Saturday. SLE. 2013 30 . AIDS.

Causes of Infarction in 100 Young Adults RG Hart and VT Miller Stroke 1983. May 11. 2013 31 . 14:110-114 Saturday.

May 11. 2013 32 .Show case Saturday.

O.58 Y. man presented with dizziness. and become coma Basilar artery thrombosis Saturday. 2013 33 . May 11.

2013 34 .Basilar artery supply the brain stem Reticular activating system(RAS) control conscious Saturday. May 11.

May 11.O.55 Y. 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 Saturday. 2013 35 .

F/U Hemorrhage in venous infarct Saturday. 2013 36 . May 11.

May 11.Clinical clues for venous stroke • • • headache before stroke onset: progressive headache. thunderclap headache. cough headache more likely to present with seizure distribution of stroke • • • • • Saturday. 2013 may be uni-or bilateral not distribute along artery territory may associated with hemorrhage tend to be subcortical clot along venous system 37 .

O. May 11.59 Y. stroke due to Infarction of right parietal lobe Saturday. 2013 hypercoagulable state 38 . man presented with acute left-right confusion Underlying Cholangio carcinoma Dx.

woman presented with proximal muscle weakness and generalized hyperreflexia Dx. May 11. Watershed infarction due to bilateral carotid artery stenosis Saturday.O. 2013 39 .A 41 Y.

2013 40 . May 11.Watershed or Border zone infarct Normal Border zone ischemia Ischemia at center of blood supply Anterior watershed Subcortical watershed Posterior watershed Saturday.

May 11.Man in the Barrel Watershed infarction -anterior -posterior Saturday. 2013 41 .

2013 42 . multiple intracranial hemorrhage Saturday. May 11.A 24 Y.O. Thai lady presented was admitted to the hospital because of an acute left arm and leg weakness for 1 day Underlying SLE Dx.

2013 43 . May 11. Intracranial hemorrhage due to CNS vasculitis Saturday.Angiogram: “Beat like pattern” Dx.

May 11.Other cause Saturday. 2013 44 .

A 37 Y.O. 2013 45 . man with abnormal visual symptoms for 2 months Saturday. May 11.

May 11. 2013 46 .Saturday.

2013 47 .Saturday. May 11.

2013 String sign 48 . May 11.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 Saturday.

4. 2013 49 . Micheli The Open Neurology Journal.Cause of carotid dissection S. 50-55 Saturday. 2010. May 11.

May 11. Saturday. 78(12): 1320–1324. 2013 50 .infectious -HIV vasculitides -coagulopathy -cardioembolism J Neurol Neurosurg Psychiatry. 2007.Stroke in HIV infection etiology Stroke in HIV includes .

HIV vasculopathy Computed tomography cerebral angiography demonstrating multifocal stenoses (arrows) of the left middle cerebral artery (MCA) in a HIV positive patient with stroke. May 11. John W. Stroke. Cole. 2013 51 . 2004. 35: 51-56 Digital subtraction angiogram demonstrating fusiform dilatation of the right second portion of the posterior cerebral artery Saturday.

Saturday. May 11. 2013 52 .

May 11. 2013 53 .. openneurons Saturday.download slide at..

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