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Stroke mimicker

and

Unusual cause of stroke


Surat Tanprawate, MD, MSc(London), FRCP(T) Division of Neurology, Chiangmai University
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Outline of my talk today


Stroke Mimicker Stroke cameleons Unusual cause of stroke
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When the time is brain... rt-PA is a good choice

Since 1995
rt-PA era
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Sudden onset of neurological decit

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

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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%
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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

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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.

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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)

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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


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Post-stroke seizure
or Todds paralysis

Stroke can produce seizures


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intracranial hemorrhage embolus

Some clinical clues to differentiate both what come rst; weak or seizure type of neurological decit recovery imaging
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Migraine-the great mimicker

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Aura alone Uncommon aura: dysphasia, weakness,


vertigo, coma

Prolong aura: more than 60 minute


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Migraine Aura
99% 31%

Typical aura: -Visual -Sensory -Speech


6%

18%

n=163
Michael B. R. et al. Brain 1996: 119, 355-361
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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
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I was reported that a young aged man came into the hospital because transient weakness of his right side of the body

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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


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Tumor and stroke-like

H98IPPOKRATIA 2008, 12, 2: 98-102

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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

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Toxic/Metabolic-???
Hypoglycemia and focal paresis -a case description

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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

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functional sensory disturbance

functional gait disorder

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


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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

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Stroke chameleons

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


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uncommon manifestation: movement disorder, behavior abnormality, pain, isolated memory loss.. etc uncommon time-course...slow progressive, uctuation
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48 Y.O. man with right side abnormal movement

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the major cause of stroke is atherosclerosis

Cardiac embolism

Atherosclerosis
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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.


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



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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

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Clinical clues
Stroke in the young No atherosclerotic risk Underlying of particular disease; SLE,
AIDS, carcinoma, migraine

Atypical presentation Fail to conventional treatment


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Causes of Infarction in 100 Young Adults


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

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Show case

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58 Y.O. man presented with dizziness, and become coma

Basilar artery thrombosis


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Basilar artery supply the brain stem

Reticular activating system(RAS) control conscious


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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

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F/U Hemorrhage in venous infarct

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Clinical clues for venous stroke



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


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may be uni-or bilateral not distribute along artery territory may associated with hemorrhage tend to be subcortical clot along venous system

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59 Y.O. man presented with acute left-right confusion

Underlying

Cholangio carcinoma
Dx. stroke due to

Infarction of right parietal lobe


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hypercoagulable state
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A 41 Y.O. woman presented with proximal muscle weakness and generalized hyperreexia

Dx. Watershed infarction due to bilateral carotid artery stenosis


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Watershed or Border zone infarct


Normal Border zone ischemia Ischemia at center of blood supply

Anterior watershed Subcortical watershed Posterior watershed


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Man in the Barrel


Watershed infarction -anterior -posterior

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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

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Angiogram: Beat like pattern

Dx. Intracranial hemorrhage due to CNS vasculitis


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Other cause

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A 37 Y.O. man with abnormal visual symptoms for 2 months

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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
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String sign
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Cause of carotid dissection

S. Micheli The Open Neurology Journal, 2010, 4, 50-55

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Stroke in HIV infection

etiology

Stroke in HIV includes - infectious -HIV vasculitides -coagulopathy -cardioembolism

J Neurol Neurosurg Psychiatry. 2007; 78(12): 13201324.

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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

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download slide at... openneurons

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