STROKE & STROKE MIMICS - cpamm.asc.org.my · Stroke Mimics •Stroke mimics- 20-30% •CT scan may...

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STROKE & STROKE MIMICS Professor Dr Hamidon Basri FPSK UPM

Transcript of STROKE & STROKE MIMICS - cpamm.asc.org.my · Stroke Mimics •Stroke mimics- 20-30% •CT scan may...

STROKE & STROKE MIMICS

Professor Dr Hamidon Basri FPSK UPM

Stroke- Definition

“ Rapidly developing clinical neurological signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin”

Stroke and Stroke Mimics

• Other disease mimicking stroke = Stroke Mimic

• Stroke mimicking other disease = Stroke Chameleon

• Important in diagnosis- Time is brain

• Thrombolysis and thrombectomy- potent treatment modality

Importance of Rapid and Accurate Recognition

• Early thrombolysis- NINDS, ECASS II

• Potential thrombectomy- MR CLEAN, DAWN

• Early intervention for secondary prevention

– EXPRESS Trial, SOS-TIA trial

• “Fast” compromising “accuracy”?

• Correct diagnosis- more appropriate treatment. Stroke vs Stroke Mimics

Stroke and Stroke Mimics

• Accuracy important in stroke diagnosis

• Ambulance,primary care, ED, Stroke team

• Joint effort

Meta-analysis of thrombolysed stroke mimics Less bleeding in stroke mimics (But unnecessary) Fast vs Accurate

Stroke and Stroke Mimics: Case 1

• 61 years old man; underlying Hpt & DM

• Sudden right sided hemiparesis 1hr onset

• Dysphasia, right hemineglect, hemianopia

• NIHSS 15

• Brain CT

Stroke and Stroke Mimics: Case 1

• Acute onset localising features- Left MCA

• Normal brain CT despite moderate clinical stroke severity

• Thrombolysis

• Thrombectomy-proximal occlusion

Impact of Thrombolysis and Thrombectomy

Thrombolysis and thrombectomy- Huge impact on outcome

Failure to

Thrombolyse*

Complications

of tPA

90

60

30

%

Medico-legal Considerations with Intravenous

Tissue Plasminogen Activator in Stroke

95%

*Failure to diagnose, failure to transfer to an institution where

thrombolysis can be given, delay in evaluating pt, failure to recommend

tPA as a treatment

5%

plaintiff-favoured verdicts

30%

Stroke Research and Treatment 2013

Stroke Mimics

• Stroke mimics- 20-30%

• CT scan may likely be normal and patient may be thrombolysed even in stroke mimics

• Brain imaging (CT/MRI) may not be helpful differentiating stroke with mimics

• Standard diagnosis- history, hard signs, and supported by imaging (which may be normal)

• Seizures

• Syncope

• Sepsis

• Sugar

• Space Occupying

Lesion

• pSychogenic

• Sakit Kepala

• OtherS- Bell’s palsy,

periph vertigo, etc.

Stroke Mimics Causes

• Progressive onset • Signs inconsistent

with symptoms • Confusion/loss of

consciousness • Seizure at onset • Cognitive

impairment • No lateralising or

focal features

Features Favouring stroke mimics

Stroke Mimics and Age

Vroomen et al JSCVD 2008

• Younger age group- Higher percentage of conversion disorder and migraine as mimics

Case 2

• 65 years old man; underlying hypertension

• Previous stroke 2 years; right hemiparesis recovered fully

• Presenting with GTC seizures.

• Noticed dense left hemiparesis and confusion.

• NIHSS 8

Brain CT- hypodense left capsular area No other changes

Stroke and Stroke Mimics

• Red flags:

– Confusion

– Seizure at onset

– Strong association to cause of seizure

• ?Eligible for thrombolysis based on clinical (NIHSS) and radiological (Brain CT) features

• ?MRI prior thrombolysis

Seizure Mimicking Stroke

• 20% of stroke mimics

• More apparent if has history of recurrent seizures stereotyped semiology

• Post stroke seizures occur late > 6 months

• Brain CT may be misinterpreted as an acute infarct corresponding to paralysis

• Todd’s paralysis- difficult to differentiate from acute stroke

Todd’s Paralysis

• 15% of seizures.

• Most common after GTC especially after clonic activity

• Usually causes hemiparesis/hemiplegia

• Can be associated with aphasia, sensory loss or visual field defect (uncommon)

• Usually lasts minutes but can last hours or even days.

Case 3

• 69 years old man

• Underlying DM/Hpt/CL

• Left hemiparesis on awakening from sleep

• Dysphasia and Confusion

• NIHSS 10

• BG 1.5 mmol/l

Case 3 • Wake-up “stroke”

• Red flags: – Features inconsistent with localisation; left

hemiparesis with dysphasia

– Hypoglycaemia

– Confusion not accompanied by other hemispheric features

• Improve on correction of hypoglycaemia

• MRI- Highly sensitive and specific for acute ischaemic stroke changes

• CT may be normal despite an actual stroke

MRI sequences for acute ischaemic stroke A: FLAIR B: DWI C: ADC

Migraine Mimicking Stroke

• Familial hemiplegic migraine – Autosomal dominant – Young females

• Other neurological deficits – Focal weakness – Hemianopia – Dysphasia

• Recurring stereotypes • Headaches may not be a prominent

feature

Functional Disorder Mimicking Stroke

• Acute weakness/sensory disturbances

• Inconsistent deficits

• Non-localising

• Positive psychogenic signs eg. Using agonist-antagonist muscle or Hoover’s sign- more important than normal MRI

• Secondary gain, La Belle Indifference

Case 4

• 57 years old woman

• Underlying Hpt

• Left LMN VII CN palsy

• On awakening

• Confusion

• Normal brain CT

• ?Bell’s palsy

Case 4

• Red flag: Confusion

• MRI acute stroke

• Brain stem involvement

• Posterior circulation may not be typical presentation

• Stroke chameleon

Conclusions

• History and examination- Important in diagnosing stroke and identifying stroke mimics

• Red flags- help in differentiating stroke mimics, improving diagnostic accuracy

• Brain imaging – assisting diagnosis

• MRI preferred for acute stroke changes

• Identifying mimics- Crucial step in acute stroke management. Facilitating thrombolysis and thrombectomy and avoiding unnecessary Rx

• Hospital Pengajar UPM • Stroke dedicated ER • Regional Emergency

Stroke Quick-response (RESQ) Strategy

• High volume stroke centre with T & T

www.strokeresq.com Facebook: www.facebook.com/strokeresq • Thrombolysis &

Thrombectomy workshop, hands-on and simulation

Thank You