Stroke Mimicker

Stroke mimicker
and
Unusual cause of stroke

Surat Tanprawate, MD, MSc(London), FRCP(T) Division of Neurology, Chiangmai University
Wednesday, March 21, 2012
Stroke Cerebrovascular accident Cerebrovascular disease

1.When the time is brain... rt-PA is a good choice
Since 1995
rt-PA era
Sudden onset of neurological decit
3 hrs->4.5 hrs->6 hrs->12 hrs
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

Dont forget that rt-PA increase risk of hemorrhage 6%
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
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. Neurology. 1999;52:1784-1792.
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% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 18.2% 3.6% 3.1%
% of all stroke mimics (n=670)
Seizure and Todds paralysis

Robert Benley Todd (1809-1860) Irish-born London physiologist
Todds 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
Exhausted seizure brain

Variant of Todds 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.
Post-stroke seizure
or Todds paralysis

Stroke can produce seizures

intracranial hemorrhage embolus
Some clinical clues to differentiate both what come rst; weak or seizure type of neurological decit 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
Migraine-the great mimicker
Aura alone Uncommon aura: dysphasia, weakness,

vertigo, coma
Prolong aura: more than 60 minute

Migraine Aura
99% 31%
Typical aura: -Visual -Sensory -Speech

6%
18%
n=163
Michael B. R. et al. Brain 1996: 119, 355-361
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 Sndor. Lancet Neurol 2004; 3: 23745

Can migraine induce infarct?

Migraine with aura (MA)
WMLs in migraine brain

Double stroke risk: women, < 45 years, smoker, oral contraceptive pill used associated with subclinical WMLs migrainous infarct
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
Hemiplegic migraine
Description
Migraine with aura including motor weakness

Familial Hemiplegic Migraine (FHM)
at least one rst- or second- degree

Sporadic Hemiplegic Migraine (SHM)
relative has migraine aura including motor weakness
no rst- or second-degree relative has

aura including motor weakness
Tumor and stroke-like
H98IPPOKRATIA 2008, 12, 2: 98-102
Tumor and stroke like

6% of brain tumor patients had symptoms that were of less than one days 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
Toxic/Metabolic-???
Hypoglycemia and focal paresis -a case description
Functional hemiparesis
Conversion disorder is the most
commonly assigned psychiatric disorder presentations of conversion disorder noted that symptoms of paresis, paralysis, or movement disorders were common and were a presentation in almost 30% of patients.
One study of emergency department
Hoovers sign: testing functional weakness

J Stone, A Carson, M Sharpe J Neurol Neurosurg Psychiatry 2005;76:i2-i12
functional sensory disturbance
functional gait disorder
J Stone, A Carson, M Sharpe J Neurol Neurosurg Psychiatry 2005;76:i2-i12

2. The clinical suggesting stroke is abrupt onset of neurological decit
Point...
Not all stroke patient come with sudden neurological decit Strokes with atypical presentations that take on the appearance of other disease process
stroke cameleons
Stroke chameleons

what is common...hemiparesis, sensory loss, ataxia, language disorder, visual loss, vertigo what is uncommon...

uncommon manifestation: movement disorder, behavior abnormality, pain, isolated memory loss.. etc uncommon time-course...slow progressive, uctuation
3. the major cause of stroke is atherosclerosis
Cardiac embolism
Atherosclerosis
Stroke can be...

Ischemic 75%
TOAST classication
Large-artery atherosclerosis(emboli/ thrombosis) Cardioembolism(high-risk/mediumrisk) Small-vessel occlusion(lacune) Stroke of other determine etiology Stroke of undetermined etiology
Hemorrhagic (25%); subarachnoid, intracerebral
HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41
TOAST, Trial of Org 10172 in Acute Stroke Treatment.
Uncommon cause of stroke... the non-atherosclerotic stroke

Dissection Inammatory 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
Clinical clues
Stroke in the young No atherosclerotic risk Underlying of particular disease; SLE,
AIDS, carcinoma, migraine
Atypical presentation Fail to conventional treatment

Causes of Infarction in 100 Young Adults

RG Hart and VT Miller Stroke 1983, 14:110-114
How to make a stroke diagnosis?
RG Hart and VT Miller Stroke 1983, 14:110-114
Show case
58 Y.O. man presented with dizziness, and become coma
Basilar artery thrombosis

Basilar artery supply the brain stem
Reticular activating system(RAS) control conscious

55 Y.O. woman presented with subacute headache and then weakness of right arm
CT Brain non-contrast
lling hyperdense along superior sagittal sinus Dx. Superior sagittal vein thrombosis
F/U Hemorrhage in venous infarct
Clinical clues for venous stroke

headache before stroke onset: progressive headache, thunderclap headache, cough headache more likely to present with seizure distribution of stroke

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

hypercoagulable state
A 41 Y.O. woman presented with proximal muscle weakness and generalized hyperreexia
Dx. Watershed infarction due to bilateral carotid artery stenosis

Watershed or Border zone infarct

Normal Border zone ischemia Ischemia at center of blood supply
Anterior watershed Subcortical watershed Posterior watershed

Man in the Barrel

Watershed infarction -anterior -posterior
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. multiple intracranial hemorrhage
Angiogram: Beat like pattern
Dx. Intracranial hemorrhage due to CNS vasculitis

Other cause
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 (Horners syndrome) Transient vision loss Ischemic stroke
String sign
Cause of carotid dissection
S. Micheli The Open Neurology Journal, 2010, 4, 50-55
Stroke in HIV infection
etiology
Stroke in HIV includes - infectious -HIV vasculitides -coagulopathy -cardioembolism
J Neurol Neurosurg Psychiatry. 2007; 78(12): 13201324.
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
download slide at... openneurons

Stroke Mimicker

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Stroke Mimicker

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Stroke mimicker

Unusual cause of stroke

Stroke Cerebrovascular accident Cerebrovascular disease

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

Sudden onset of neurological decit

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

Wednesday, March 21, 2012

Stroke mimics, non-vascular conditions that simulate stroke

250 rt-PA treated patients, 243 (97.2%) had strokes and

7 (2.8%) were mimics (and was received rt-PA

Wednesday, March 21, 2012

Wednesday, March 21, 2012

Condition that mimic stroke

% of all stroke mimics (n=670)

Wednesday, March 21, 2012

Seizure and Todds paralysis

Exhausted seizure brain

Variant of Todds paralysis

Postictal apraxia and prolonged postictal

Bilateral Todd's paralysis after focal

Mute postseizure patient: an unusual

manifestation of Todd's phenomenon.

intracranial hemorrhage embolus

Migraine-the great mimicker

Wednesday, March 21, 2012

Aura alone Uncommon aura: dysphasia, weakness,

Prolong aura: more than 60 minute

Typical aura: -Visual -Sensory -Speech

Migraine aura vs TIA

Jean Schoenen and Peter S Sndor. Lancet Neurol 2004; 3: 23745

Can migraine induce infarct?

Migraine with aura including motor weakness

at least one rst- or second- degree

relative has migraine aura including motor weakness

no rst- or second-degree relative has

Tumor and stroke-like

H98IPPOKRATIA 2008, 12, 2: 98-102

Wednesday, March 21, 2012

Tumor and stroke like

Wednesday, March 21, 2012

Wednesday, March 21, 2012

Wednesday, March 21, 2012

One study of emergency department

Wednesday, March 21, 2012

Hoovers sign: testing functional weakness

functional sensory disturbance

functional gait disorder

J Stone, A Carson, M Sharpe J Neurol Neurosurg Psychiatry 2005;76:i2-i12

2. The clinical suggesting stroke is abrupt onset of neurological decit

Wednesday, March 21, 2012

3. the major cause of stroke is atherosclerosis

Stroke can be...

Hemorrhagic (25%); subarachnoid, intracerebral

HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41

TOAST, Trial of Org 10172 in Acute Stroke Treatment.

Wednesday, March 21, 2012

Uncommon cause of stroke... the non-atherosclerotic stroke

Dissection Inammatory vasculopathy Trauma Moyamoya Radiation vasculopathy Inherit disorder

Atypical presentation Fail to conventional treatment

Causes of Infarction in 100 Young Adults

Wednesday, March 21, 2012

How to make a stroke diagnosis?

RG Hart and VT Miller Stroke 1983, 14:110-114

Wednesday, March 21, 2012