1
|
Wouters A, Scheldeman L, Liessens H, Dupont P, Boutitie F, Cheng B, Ebinger M, Endres M, Fiebach JB, Gerloff C, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Thijs V, Thomalla G, Lemmens R. Sex differences in imaging and clinical characteristics of patients from the WAKE-UP trial. Eur J Neurol 2023; 30:641-647. [PMID: 36349887 PMCID: PMC10099623 DOI: 10.1111/ene.15629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND PURPOSE Sex-based differences in acute ischemic stroke are a well-known phenomenon. We aimed to explore these differences between women and men in the Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke (WAKE-UP) trial. METHODS We compared baseline demographic and imaging characteristics (visual fluid-attenuated inversion recovery [FLAIR] positivity, relative FLAIR signal intensity, collateral status) between women and men in all screened patients. In randomized patients (i.e., those with diffusion-weighted imaging (DWI)-FLAIR mismatch), we evaluated a modifying role of sex on the treatment effect of alteplase in multivariable logistic regression, with treatment adjusted for National Institute of Health Stroke Scale (NIHSS) score and age. Dependent variables were modified Rankin Scale (mRS) score of 0-1 at 90 days and distribution of mRS scores at 90 days. RESULTS Of 1362 screened patients, 529 (38.8%) were women. Women were older than men, had higher baseline NIHSS scores and smoked less frequently. FLAIR positivity of the DWI lesion was equally present in women (174/529, 33.1%) and men (273/833, 33.3%; p = 1.00) and other imaging variables also did not differ between the sexes. In a total of 503 randomized patients, of whom 178 were women (35.4%), sex did not modify the treatment effect of alteplase on mRS score 0-1 or on the total distribution of mRS scores. CONCLUSION As in many other stroke trials, more men than women were included in the WAKE-UP trial, but the presence of a visual DWI-FLAIR mismatch and the relative FLAIR signal intensity did not differ between the sexes. The treatment effect of alteplase was not modified by sex.
Collapse
Affiliation(s)
- Anke Wouters
- Neurology, Amsterdam University Medical Centers location AMC, Amsterdam, the Netherlands
- Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Leuven, Belgium
- Center for Brain & Disease Research, Laboratory of Neurobiology, VIB, Leuven, Belgium
| | - Lauranne Scheldeman
- Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Leuven, Belgium
- Center for Brain & Disease Research, Laboratory of Neurobiology, VIB, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | | | - Patrick Dupont
- Department of Neurosciences, Laboratory for Cognitive Neurology, KU Leuven - University of Leuven, Leuven, Belgium
- Leuven Brain Institute, Leuven, Belgium
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Université Lyon, Lyon, France
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
- Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité- Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
- ExcellenceCluster NeuroCure, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, UK
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1; Hospices Civils de Lyon, Lyon, France
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image (IDI), Hospital Dr Josep Trueta, Institut d'Investigació Biomedica de Girona (IDIBGI), Parc Hospitalari Marti i Julia de Salt - Edifici M2, Girona, Spain
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Vincent Thijs
- Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Victoria, Australia
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven - University of Leuven, Leuven, Belgium
- Center for Brain & Disease Research, Laboratory of Neurobiology, VIB, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
2
|
Hsia AW, Luby ML, Leigh R, Lynch JK, Nadareishvili Z, Benson RT, Kalaria C, Burton SP, Latour L. Prevalence of Imaging Targets in Patients With Minor Stroke Selected for IV tPA Treatment Using MRI: The Treatment of Minor Stroke With MRI Evaluation Study (TIMES). Neurology 2021; 96:e1301-e1311. [PMID: 33472921 DOI: 10.1212/wnl.0000000000011527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/13/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the IV tissue plasminogen activator (tPA) treatment rate of patients with minor acute ischemic stroke (mAIS) at our centers and compare the frequency of MRI targets by treatment stratification and clinical severity, we evaluated clinical characteristics and baseline MRIs for tPA-treated and untreated patients. METHODS Patients with ischemic stroke from 2015 to 2017 with admit NIH Stroke Scale (NIHSS) <6 were considered. The treated cohort received standard IV tPA and was screened with baseline MRI. The untreated cohort received no acute intervention and baseline MRI was <4 hours from onset. Patients were stratified into "clearly" and "not clearly" disabling deficits by NIHSS elements. Baseline MRI was evaluated by independent raters for AIS targets, with frequencies compared between groups. RESULTS Of 255 patients with mAIS ≤4.5 hours from onset, 140 (55%) received IV tPA, accounting for 46% of all IV tPA patients (n = 305). Eighty-five percent (n = 119) were screened with baseline MRI and had significantly more frequent imaging targets compared to those untreated (n = 90). Of this treated cohort, 75% (n = 89) were not clearly disabling. Except for perfusion-diffusion mismatch (81% clearly disabling vs 56% not clearly disabling [p = 0.036]), there were no significant differences in the frequency of imaging targets across the treated cohort stratified by clinical severity. CONCLUSIONS In MRI-screened mAIS, imaging targets were more frequently seen in patients treated with IV tPA, with similar frequencies even in those without clearly disabling deficits. MRI targets could be used to guide thrombolytic therapy in patients with mAIS; however, a randomized trial is needed to demonstrate efficacy.
Collapse
Affiliation(s)
- Amie W Hsia
- From the Stroke Branch (A.W.H., M.L.L., R.L., J.K.L., Z.N., R.T.B., C.K., S.P.B., L.L.), NIH/National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.K., S.P.B.), Washington, DC; and Suburban Hospital (Z.N.), Johns Hopkins Medicine, Bethesda, MD.
| | - Marie L Luby
- From the Stroke Branch (A.W.H., M.L.L., R.L., J.K.L., Z.N., R.T.B., C.K., S.P.B., L.L.), NIH/National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.K., S.P.B.), Washington, DC; and Suburban Hospital (Z.N.), Johns Hopkins Medicine, Bethesda, MD
| | - Richard Leigh
- From the Stroke Branch (A.W.H., M.L.L., R.L., J.K.L., Z.N., R.T.B., C.K., S.P.B., L.L.), NIH/National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.K., S.P.B.), Washington, DC; and Suburban Hospital (Z.N.), Johns Hopkins Medicine, Bethesda, MD
| | - John K Lynch
- From the Stroke Branch (A.W.H., M.L.L., R.L., J.K.L., Z.N., R.T.B., C.K., S.P.B., L.L.), NIH/National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.K., S.P.B.), Washington, DC; and Suburban Hospital (Z.N.), Johns Hopkins Medicine, Bethesda, MD
| | - Zurab Nadareishvili
- From the Stroke Branch (A.W.H., M.L.L., R.L., J.K.L., Z.N., R.T.B., C.K., S.P.B., L.L.), NIH/National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.K., S.P.B.), Washington, DC; and Suburban Hospital (Z.N.), Johns Hopkins Medicine, Bethesda, MD
| | - Richard T Benson
- From the Stroke Branch (A.W.H., M.L.L., R.L., J.K.L., Z.N., R.T.B., C.K., S.P.B., L.L.), NIH/National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.K., S.P.B.), Washington, DC; and Suburban Hospital (Z.N.), Johns Hopkins Medicine, Bethesda, MD
| | - Chandni Kalaria
- From the Stroke Branch (A.W.H., M.L.L., R.L., J.K.L., Z.N., R.T.B., C.K., S.P.B., L.L.), NIH/National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.K., S.P.B.), Washington, DC; and Suburban Hospital (Z.N.), Johns Hopkins Medicine, Bethesda, MD
| | - Shannon P Burton
- From the Stroke Branch (A.W.H., M.L.L., R.L., J.K.L., Z.N., R.T.B., C.K., S.P.B., L.L.), NIH/National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.K., S.P.B.), Washington, DC; and Suburban Hospital (Z.N.), Johns Hopkins Medicine, Bethesda, MD
| | - Larry Latour
- From the Stroke Branch (A.W.H., M.L.L., R.L., J.K.L., Z.N., R.T.B., C.K., S.P.B., L.L.), NIH/National Institute of Neurological Disorders and Stroke, Bethesda, MD; MedStar Washington Hospital Center (A.W.H., R.T.B., C.K., S.P.B.), Washington, DC; and Suburban Hospital (Z.N.), Johns Hopkins Medicine, Bethesda, MD
| |
Collapse
|
3
|
Wijerathne H, Witek MA, Baird AE, Soper SA. Liquid biopsy markers for stroke diagnosis. Expert Rev Mol Diagn 2020; 20:771-788. [PMID: 32500751 PMCID: PMC8157911 DOI: 10.1080/14737159.2020.1777859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/01/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION There is a short time window (4.5 h) for the effective treatment of acute ischemic stroke (AIS), which uses recombinant tissue plasminogen activator (rt-PA). Unfortunately, this short therapeutic timeframe is a contributing factor to the relatively small number of patients (~7%) that receive rt-PA. While neuroimaging is the major diagnostic for AIS, more timely decisions could be made using a molecular diagnostic. AREAS COVERED In this review, we survey neuroimaging techniques used to diagnose stroke and their limitations. We also highlight the potential of various molecular/cellular biomarkers, especially peripheral blood-based (i.e. liquid biopsy) biomarkers, for diagnosing stroke to allow for precision decisions on managing stroke in a timely manner. Both protein and nucleic acid molecular biomarkers are reviewed. In particular, mRNA markers are discussed for AIS and hemorrhagic stroke diagnosis sourced from both cells and extracellular vesicles. EXPERT OPINION While there are a plethora of molecular markers for stroke diagnosis that have been reported, they have yet to be FDA-cleared. Possible reasons include the inability for these markers to appear in sufficient quantities for highly sensitive clinical decisions within the rt-PA therapeutic time.
Collapse
Affiliation(s)
- Harshani Wijerathne
- Department of Chemistry, The University of Kansas, Lawrence, KS, USA
- Center of BioModular Multiscale Systems for Precision Medicine, The University of Kansas, Lawrence, KS, USA
| | - Malgorzata A. Witek
- Department of Chemistry, The University of Kansas, Lawrence, KS, USA
- Center of BioModular Multiscale Systems for Precision Medicine, The University of Kansas, Lawrence, KS, USA
- Department of Cancer Biology and KU Cancer Center, University of Kansas Medical Center, Cancer Center, Kansas City, KS, USA
| | - Alison E. Baird
- Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Steven A. Soper
- Department of Chemistry, The University of Kansas, Lawrence, KS, USA
- Center of BioModular Multiscale Systems for Precision Medicine, The University of Kansas, Lawrence, KS, USA
- Department of Cancer Biology and KU Cancer Center, University of Kansas Medical Center, Cancer Center, Kansas City, KS, USA
- Bio Engineering Program, The University of Kansas, Lawrence, KS, USA
- Department of Mechanical Engineering, The University of Kansas, Lawrence, KS, USA
- Biofluidica, Inc, San Diego, CA, USA
| |
Collapse
|
4
|
Pauletto G, Bax F, Gigli GL, Lorenzut S, Verriello L, Corazza E, Valente M. Status epilepticus mimicking stroke recurrence. Epilepsy Behav 2020; 104:106509. [PMID: 31629647 DOI: 10.1016/j.yebeh.2019.106509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/14/2019] [Accepted: 08/16/2019] [Indexed: 12/25/2022]
Abstract
AIM OF THE STUDY The aim of the study was to evaluate the clinical characteristics of patients with previous stroke (either ischemic or hemorrhagic), who developed status epilepticus (SE) mimicking a stroke relapse. MATERIALS AND METHODS We performed a retrospective cohort study of patients brought to hospital by the emergency service between December 2016 and January 2018 with a stroke code as possible candidates for intravenous thrombolysis and who had already have a previous stroke. Among them, patients admitted for negative symptoms and finally discharged with a diagnosis of SE mimicking stroke were selected and their clinical characteristics collected. All patients underwent routine blood sample analysis, head computed tomography (CT) scan and, when indicated, CT angiography and CT-perfusion imaging of the head. After admission in our stroke unit, an Electroencephalogram (EEG) was performed within 3 h in patients suspected with SE, then classified according to International League Against Epilepsy (ILAE) classification (2015). Outcome measures were SE duration, antiepileptic drugs (AEDs) administered, mortality at 12 months, Engel scale, and modified Rankin scale (m-RS) at 6 months. A second cohort included those consecutive patients discharged with a true stroke relapse in the same considered time span. Clinical characteristics of these two cohorts were compared using Mann-Whitney test or Student t-test (Confidence Interval (C.I.) 95%, p < 0.05) for continuous variable and Fisher exact test or Pearson-Chi test for dichotomic variables (p < 0.05). Survival rates were calculated, and a Log-Rank test was performed to evaluate differences in survival distribution. Only in the group with SE, m-RS at 6 months and recurrence of SE were also evaluated. RESULTS Eleven patients were discharged with a diagnosis of SE mimicking stroke and 65 patients with stroke relapse. Temporal lobe localization was significantly more represented in group with SE (p = 0.036) while there was no difference regarding age, sex, and National Institutes of Health Stroke Scale (NIHSS). The m-RS was significantly higher in patients with hemorrhage relapse, mainly due to the high incidence of amyloid angiopathy in this subgroup. Status epilepticus recurred in 36.4% of patients, presenting with the same clinical features, and most patients (62.5%) achieved a good seizure control at 6 months (Engel scale = 1). A difference in mortality at 12 months (all cause considered) appeared only when distinguishing strokes between ischemic and hemorrhagic (Chi-Square: 10.711, p < 0.005). DISCUSSION AND CONCLUSION Status epilepticus is not infrequent in patients with previous stroke and may present with negative neurological symptoms, thus mimicking a stroke recurrence. EEG should be considered as a potential diagnostic tool in the acute stroke setting, at least in patients with previous stroke. This article is part of the Special Issue "Seizures & Stroke".
Collapse
Affiliation(s)
| | - Francesco Bax
- Clinical Neurology Unit, University of Udine, Udine, Italy; Department of Medicine (DAME), University of Udine, Udine, Italy.
| | - Gian Luigi Gigli
- Clinical Neurology Unit, University of Udine, Udine, Italy; Department of Medicine (DAME), University of Udine, Udine, Italy; Department of Mathematics, Informatics and Physics (DMIF), University of Udine, Udine, Italy
| | | | | | - Elisa Corazza
- Clinical Neurology Unit, University of Udine, Udine, Italy; Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology Unit, University of Udine, Udine, Italy; Department of Medicine (DAME), University of Udine, Udine, Italy
| |
Collapse
|
5
|
Simhan S, Thijs V, Mancuso S, Tsivgoulis G, Katsanos A, Alexandrov AV, Kanaan RA. The outcome of acute functional neurological disorder: a meta-analysis of stroke-mimic presentations. J Neurol 2020; 267:1353-1357. [DOI: 10.1007/s00415-020-09709-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/10/2020] [Accepted: 01/11/2020] [Indexed: 11/25/2022]
|
6
|
Garg R, Rech MA, Schneck M. Stroke Mimics: An Important Source of Bias in Acute Ischemic Stroke Research. J Stroke Cerebrovasc Dis 2019; 28:2475-2480. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/05/2019] [Accepted: 06/15/2019] [Indexed: 01/22/2023] Open
|
7
|
Ali-Ahmed F, Federspiel JJ, Liang L, Xu H, Sevilis T, Hernandez AF, Kosinski AS, Prvu Bettger J, Smith EE, Bhatt DL, Schwamm LH, Fonarow GC, Peterson ED, Xian Y. Intravenous Tissue Plasminogen Activator in Stroke Mimics. Circ Cardiovasc Qual Outcomes 2019; 12:e005609. [PMID: 31412730 PMCID: PMC6699639 DOI: 10.1161/circoutcomes.119.005609] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The necessity for rapid evaluation and treatment of acute ischemic stroke with intravenous tPA (tissue-type plasminogen activator) may increase the risk of administrating tPA to patients presenting with noncerebrovascular conditions that closely resemble stroke (stroke mimics). However, there are limited data on thrombolysis safety in stroke mimics. METHODS AND RESULTS Using data from the Get With The Guidelines-Stroke Registry, we identified 72 582 patients with suspected ischemic stroke treated with tPA from 485 US hospitals between January 2010 and December 2017. We documented the use of tPA in stroke mimics, defined as patients who present with stroke-like symptoms, but after workup are determined not to have suffered from a stroke or transient ischemic attack, and compared characteristics and outcomes in stroke mimics versus those with ischemic stroke. Overall, 3.5% of tPA treatments were given to stroke mimics. Among them, 38.2% had a final nonstroke diagnoses of migraine, functional disorder, seizure, and electrolyte or metabolic imbalance. Compared with tPA-treated true ischemic strokes, tPA-treated mimics were younger (median 54 versus 71 years), had a less severe National Institute of Health Stroke Scale (median 6 versus 8), and a lower prevalence of cardiovascular risk factors, except for a higher prevalence of prior stroke/transient ischemic attack (31.3% versus 26.1%, all P<0.001). The rate of symptomatic intracranial hemorrhage was lower in stroke mimics (0.4%) as compared with 3.5% in ischemic strokes (adjusted odds ratio, 0.29; 95% CI, 0.17-0.50). In-hospital mortality rate was significantly lower in stroke mimics (0.8% versus 6.2%, adjusted odds ratio, 0.31; 95% CI, 0.20-0.49). Patients with stroke mimics were more likely to be discharged to home (83.8% versus 49.3%, adjusted odds ratio, 2.97; 95% CI, 2.59-3.42) and to ambulate independently at discharge (78.6% versus 50.6%, adjusted odds ratio, 1.86; 95% CI, 1.61-2.14). CONCLUSIONS In this large cohort of patients treated with tPA, relatively few patients who received tPA for presumed stroke were ultimately not diagnosed with a stroke or transient ischemic attack. The complication rates associated with tPA in stroke mimics were low. Despite the potential risk of administering tPA to stroke mimics, opportunity remains for continued improvement in the rapid and accurate diagnosis and treatment of ischemic stroke.
Collapse
Affiliation(s)
- Fatima Ali-Ahmed
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.).,Department of Cardiology, Beaumont Health, Dearborn, MI (F.A.-A.)
| | - Jerome J Federspiel
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.)
| | - Li Liang
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Haolin Xu
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Theresa Sevilis
- Department of Neurology, Duke University Medical Center, Durham, NC (T.S., Y.X.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Janet Prvu Bettger
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Alberta, CA (E.E.S.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Lee H Schwamm
- Division of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.)
| | - Gregg C Fonarow
- Division of Cardiology, University of California, LA (G.C.F.)
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Ying Xian
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.).,Department of Neurology, Duke University Medical Center, Durham, NC (T.S., Y.X.)
| |
Collapse
|
8
|
Barnett C, Armes J, Smith C. Speech, language and swallowing impairments in functional neurological disorder: a scoping review. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2019; 54:309-320. [PMID: 30592118 DOI: 10.1111/1460-6984.12448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/27/2018] [Accepted: 12/04/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Functional neurological disorder (FND) is common across healthcare settings. The Diagnostic and Statistical Manual of Mental Disorders states that speech and swallowing symptoms can be present in FND. Despite this, there is a dearth of guidelines for speech and language therapists (SLTs) for this client group. AIMS To address the following question in order to identify gaps for further research: What is known about speech, language and swallowing symptoms in patients with FND? METHODS & PROCEDURES A scoping review was conducted. Six healthcare databases were searched for relevant literature: CINAHL PLUS, MEDLINE, ProQuest Nursing and Allied Health Professionals, Science Citation Index, Scopus, and PsychINFO. The following symptoms were excluded from the review: dysphonia, globus pharyngeus, dysfluency, foreign accent syndrome and oesophageal dysphagia. MAIN CONTRIBUTION A total of 63 papers were included in the final review; they ranged in date from 1953 to 2018. Case studies were the most frequent research method (n = 23, 37%). 'Psychogenic' was the term used most frequently (n = 24, 38%), followed by 'functional' (n = 21, 33%). Speech symptoms were reported most frequently (n = 41, 65%), followed by language impairments (n = 35, 56%) and dysphagia (n = 13, 21%). Only 11 publications comment on the involvement of SLTs. Eight papers report direct speech and language therapy input; however, none studied the effectiveness of speech and language therapy. CONCLUSIONS & IMPLICATIONS Speech, language and swallowing symptoms do occur in patients with FND, yet it is a highly under-researched area. Further research is required to create a set of positive diagnostic criteria, gather accurate data on numbers of patients with FND and speech, language or swallowing symptoms, and to evaluate the effectiveness of direct speech and language therapy involvement.
Collapse
Affiliation(s)
- Caroline Barnett
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jean Armes
- Birmingham Community Healthcare NHS Trust, Birmingham, UK
| | - Christina Smith
- Department of Language and Cognition, University College London, London, UK
| |
Collapse
|
9
|
Bushnell C, Howard VJ, Lisabeth L, Caso V, Gall S, Kleindorfer D, Chaturvedi S, Madsen TE, Demel SL, Lee SJ, Reeves M. Sex differences in the evaluation and treatment of acute ischaemic stroke. Lancet Neurol 2019; 17:641-650. [PMID: 29914709 DOI: 10.1016/s1474-4422(18)30201-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 05/02/2018] [Accepted: 05/14/2018] [Indexed: 10/14/2022]
Abstract
With the greater availability of treatments for acute ischaemic stroke, including advances in endovascular therapy, personalised assessment of patients before treatment is more important than ever. Women have a higher lifetime risk of stroke; therefore, reducing potential sex differences in the acute stroke setting is crucial for the provision of equitable and fast treatment. Evidence indicates sex differences in prevalence and types of non-traditional stroke symptoms or signs, prevalence of stroke mimics, and door-to-imaging times, but no substantial differences in use of emergency medical services, stroke knowledge, eligibility for or access to thrombolysis or thrombectomy, or outcomes after either therapy. Women presenting with stroke mimics or non-traditional stroke symptoms can be misdiagnosed, which can lead to inappropriate triage, and acute treatment delays. It is essential for health-care providers to recognise possible sex differences in stroke symptoms, signs, and mimics. Future studies focused on confounders that affect treatment and outcomes, such as age and pre-stroke function, are also needed.
Collapse
Affiliation(s)
- Cheryl Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA.
| | - Virginia J Howard
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lynda Lisabeth
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Valeria Caso
- Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Stacie L Demel
- Department of Neurology & Ophthalmology and Pharmacology & Toxicology, Michigan State University, East Lansing, MI, USA
| | - Seung-Jae Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Mathew Reeves
- Department of Epidemiology, Michigan State University, East Lansing, MI, USA
| |
Collapse
|
10
|
Arokszallasi T, Balogh E, Csiba L, Fekete I, Fekete K, Olah L. Acute alcohol intoxication may cause delay in stroke treatment - case reports. BMC Neurol 2019; 19:14. [PMID: 30696413 PMCID: PMC6350361 DOI: 10.1186/s12883-019-1241-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/16/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The signs and symptoms of acute alcohol intoxication resemble those of vertebrobasilar stroke. Due to their shared symptoms including double vision, nystagmus, dysarthria, and ataxia, the differential diagnosis of alcohol intoxication and vertebrobasilar stroke may pose a challenge. Moreover, if alcohol intoxication and stroke occur simultaneously, the signs and symptoms of stroke may be attributed to the effects of alcohol, leading to delayed stroke diagnosis and failure to perform reperfusion therapy. CASE PRESENTATIONS Three cases of alcohol intoxication and stroke are presented. The first patient (female, 50 years old) had dysarthria, nystagmus and trunk ataxia on admission. Her blood alcohol level was 2.3‰. The symptoms improved after forced diuresis, but 5.5 h later progression was observed, and the patient developed diplopia and dysphagia in addition to her initial symptoms. Angiography showed occlusion of the basilar artery. Intraarterial thrombolysis was performed. The second patient (male, 62 years old) developed diplopia, dysarthria and trunk ataxia after consuming 4-units of alcohol, and his symptoms were attributed to alcohol intoxication. Two hours later, neurological examination revealed dysphagia and mild right-sided hemiparesis, which questioned the causal relationship between the symptoms and alcohol consumption. Cerebral CT was negative, and intravenous thrombolysis was administered. The third patient (male, 55 years old) consumed 10 units of alcohol before falling asleep. Three hours later, his relatives tried to wake him up. He was unresponsive, which was attributed to alcohol intoxication. When he woke up 8 h later, right-sided hemiparesis and aphasia were observed, and cerebral CT already revealed irreversible ischemic changes. CONCLUSIONS Our cases show that alcohol consumption may interfere with stroke diagnosis by mimicking the signs and symptoms of vertebrobasilar stroke. Moreover, attributing the symptoms of stroke to alcohol intoxication may delay stroke diagnosis resulting in failure of reperfusion therapy. Based on our observations we conclude that stroke should be considered in the case of worsening symptoms, dysphagia, hemiparesis and disproportionately severe signs that cannot be attributed to the amount of alcohol consumed. In the case of ambiguity, ambulance should be called, and if stroke cannot be excluded, specific therapy should be administered.
Collapse
Affiliation(s)
- Tamas Arokszallasi
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary.
| | - Eszter Balogh
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary
| | - Laszlo Csiba
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary.,Cerebrovascular and Neurodegenerative Research Group of the Hungarian Academy of Sciences, Moricz Zs. krt 22, Debrecen, 4032, Hungary
| | - Istvan Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary
| | - Klara Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary
| | - Laszlo Olah
- Department of Neurology, Faculty of Medicine, University of Debrecen, Moricz Zs. krt 22, Debrecen, 4032, Hungary
| |
Collapse
|
11
|
Hextrum S, Biller J. Clinical Distinction of Cerebral Ischemia and Triaging of Patients in the Emergency Department. Neuroimaging Clin N Am 2018; 28:537-549. [DOI: 10.1016/j.nic.2018.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
12
|
Morales H, Kong M. Stroke Mimics: The Quest for Leptomeningeal Anastomoses and Isolated Diffusion-Weigthed MR Signal. Semin Ultrasound CT MR 2018; 39:425-440. [PMID: 30244758 DOI: 10.1053/j.sult.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Stroke is caused by occlusion of a medium- or large-sized vessel in the brain. The treatment with either intravenous or intra-arterial thrombolysis is based on an accurate and time-sensitive diagnosis. On clinical and imaging grounds a number of entities-seizures, toxic-metabolic, infectious, or demyelinating diseases-can mimic stroke. Identifying them is paramount as the treatment differs significantly. Prior imaging reviews have focused on the nonterritorial distribution of these mimics. However, some important questions arise here. Are the vascular territories and their boundaries invariable in the human brain? Where should we draw the lines separating arterial territories? van der Zwan and colleagues addressed these questions decades ago. For him and others, the leptomeningeal anastomoses-a contentious concept for some but increasingly linked to collateral flow in stroke-is an important anatomic structure with significant variations in their distribution and pathophysiology. Variations in blood supply appear larger that traditionally taught. We revisit this concept and entertained their implications in cases of stroke mimics. For instance, the distribution of abnormalities in some toxic-metabolic processes appear to correlate with areas where rich leptomeningeal anastomoses are expected. We will also explore the concept of hyperintense signal on diffusion weighted-imaging with no correlated changes on apparent diffusion coefficient maps. We name this finding as "isolated DWI signal" and lay-out its importance in the recognition of many entities mimicking stroke. Taking together, the discussed anatomic and imaging concepts will help radiologists and clinicians to recognize not only the common but the unusual entities imitating stroke in the emergency room.
Collapse
Affiliation(s)
- Humberto Morales
- Section of Neuroradiology, University of Cincinnati Medical Center.
| | - Marshall Kong
- Section of Neuroradiology, University of Cincinnati Medical Center
| |
Collapse
|
13
|
Terrin A, Toldo G, Ermani M, Mainardi F, Maggioni F. When migraine mimics stroke: A systematic review. Cephalalgia 2018; 38:2068-2078. [PMID: 29661036 DOI: 10.1177/0333102418767999] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Migraine with aura may mimic an acute ischemic stroke, so that an improper administration of thrombolytic treatment can expose migrainous patients to severe adverse effects. METHODS This systematic review quantifies the relevance of migraine with aura among stroke mimics, checking for thrombolysis' safety in these patients. We reviewed the literature after 1995, distinguishing from studies dealing with stroke mimics treated with systemic thrombolysis and those who were not treated with systemic thrombolysis. RESULTS Migraine with aura is responsible for 1.79% (CI 95% 0.82-3.79%) of all the emergency Stroke Unit evaluations and it represents 12.24% (CI 95% 6.34-22.31%) of stroke mimics in the group not treated with systemic thrombolysis. 6.65% (CI 95% 4.32-9.78%) of systemic thrombolysis administrations are performed in patients without an acute ischemic stroke. Migraine with aura is responsible for 17.91% of these (CI 95% 13.29-23.71%). The reported rate of adverse events seems extremely low (0.01%). CONCLUSION Migraine with aura is the third most common stroke mimic, following seizures and psychiatric disorders; it is responsible for about 18% of all improper thrombolytic treatments. Despite the absence of strong supporting data, thrombolysis in migraine with aura seems to be a procedure with an extremely low risk of adverse events.
Collapse
Affiliation(s)
- Alberto Terrin
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | - Giulia Toldo
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | - Mario Ermani
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | | | - Ferdinando Maggioni
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| |
Collapse
|
14
|
AbdelRazek MA, Gutierrez J, Mampre D, Cervantes-Arslanian A, Ormseth C, Haussen D, Thakur KT, Lyons JL, Smith BR, O'Connor O, Willey JZ, Mateen FJ. Intravenous Thrombolysis for Stroke and Presumed Stroke in Human Immunodeficiency Virus-Infected Adults: A Retrospective, Multicenter US Study. Stroke 2018; 49:228-231. [PMID: 29273597 DOI: 10.1161/strokeaha.117.019570] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 11/04/2017] [Accepted: 11/08/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Human immunodeficiency virus (HIV) infection has been shown to increase both ischemic and hemorrhagic stroke risks, but there are limited data on the safety and outcomes of intravenous thrombolysis with tPA (tissue-type plasminogen activator) for acute ischemic stroke in HIV-infected patients. METHODS A retrospective chart review of intravenous tPA-treated HIV patients who presented with acute stroke symptoms was performed in 7 large inner-city US academic centers (various search years between 2000 and 2017). We collected data on HIV, National Institutes of Health Stroke Scale score, ischemic stroke risk factors, opportunistic infections, intravenous drug abuse, neuroimaging findings, and modified Rankin Scale score at last follow-up. RESULTS We identified 33 HIV-infected patients treated with intravenous tPA (mean age, 51 years; 24 men), 10 of whom were stroke mimics. Sixteen of 33 (48%) patients had an HIV viral load less than the limit of detection while 10 of 33 (30%) had a CD4 count <200/mm3. The median National Institutes of Health Stroke Scale score at presentation was 9, and mean time from symptom onset to tPA was 144 minutes (median, 159). The median modified Rankin Scale score for the 33-patient cohort was 1 and for the 23-patient actual stroke cohort was 2, measured at a median of 90 days poststroke symptom onset. Two patients had nonfatal hemorrhagic transformation (6%; 95% confidence interval, 1%-20%), both in the actual stroke group. Two patients had varicella zoster virus vasculitis of the central nervous system, 1 had meningovascular syphilis, and 7 other patients were actively using intravenous drugs (3 cocaine, 1 heroin, and 3 unspecified), none of whom had hemorrhagic transformation. CONCLUSIONS Most HIV-infected patients treated with intravenous tPA for presumed and actual acute ischemic stroke had no complications, and we observed no fatalities. Stroke mimics were common, and thrombolysis seems safe in this group. We found no data to suggest an increased risk of intravenous tPA-related complications because of concomitant opportunistic infections or intravenous drug abuse.
Collapse
Affiliation(s)
- Mahmoud A AbdelRazek
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.)
| | - Jose Gutierrez
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.)
| | - David Mampre
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.)
| | - Anna Cervantes-Arslanian
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.)
| | - Cora Ormseth
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.)
| | - Diogo Haussen
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.)
| | - Kiran T Thakur
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.)
| | - Jennifer L Lyons
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.)
| | - Bryan R Smith
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.)
| | - Owen O'Connor
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.)
| | - Joshua Z Willey
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.)
| | - Farrah J Mateen
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.A.A., O.O., F.J.M.); Department of Neurology, Columbia University Medical Center, New York, NY (J.G., K.T.T., J.Z.W.); Department of Neurology, Yale-New Haven Hospital, CT (D.M., C.O.); Department of Neurology, Boston University School of Medicine, MA (A.C.-A.); Department of Neurology, University of Miami Hospital, FL (D.H.); Department of Neurology, Brigham and Women's Hospital-Harvard Medical School, Boston, MA (J.L.L.); and Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, Bethesda, MD (B.R.S.).
| |
Collapse
|
15
|
Ridolfi M, Granato A, Polverino P, Furlanis G, Ukmar M, Zorzenon I, Manganotti P. Migrainous aura as stroke-mimic: The role of perfusion-computed tomography. Clin Neurol Neurosurg 2018; 166:131-135. [DOI: 10.1016/j.clineuro.2018.01.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 01/11/2018] [Accepted: 01/28/2018] [Indexed: 10/18/2022]
|
16
|
Olindo S, Chardonnet M, Renou P, Coignion C, Debruxelles S, Poli M, Sagnier S, Rouanet F, Sibon I. Clinical Predictors of Stroke Mimics in Patients Treated with Recombinant Tissue Plasminogen Activator according to a Normal Multimodal Computed Tomography Imaging. J Stroke Cerebrovasc Dis 2017; 27:454-459. [PMID: 29128327 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/24/2017] [Accepted: 09/18/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Multimodal computed tomography imaging (MCTI) is increasingly used for rapid assessment of acute stroke. We investigated characteristics and final diagnoses of patients treated with recombinant tissue plasminogen activator (rt-PA) while admission imaging was unremarkable. METHODS From our prospectively collected stroke database (2013-2016), we identified consecutive patients treated with rt-PA on the basis of an unremarkable brain MCTI and assessed with a 24-hour follow-up brain magnetic resonance imaging (MRI). Demographic data, medical history, score on the 15-item National Institute of Health Stroke Scale, and final diagnosis were considered. Absence of MRI infarction and alternate diagnosis defined stroke mimics (SMs). Univariable and multivariable logistic regression analyses identified factors predictive of SMs. RESULTS Sixty-eight (47.9%) SMs, 63 (44.4%) strokes, and 11 (7.7%) aborted strokes were found. SMs had more often aphasia (P = .003) and hemianopia (P = .0008), whereas upper limb weakness (ULW) (P = .03) and limb ataxia (P = .002) were more prevalent in strokes. Headache (adjusted odds ratio [Adj. OR], 3.89 [95% confidence interval {CI} 1.44-10.47]), relevant history of epilepsy, migraine, dementia or depression (Adj. OR 3.66 [95% CI 1.31-10.18]), unilateral sensory loss (Adj. OR 2.60 [95% CI 1.05-6.45]), and hemianopia (Adj. OR 4.94 [95% CI 1.46-16.77]) were independent predictors of SMs whereas ULW (Adj. OR 3.16 [95% CI 1.28-7.82]) and ataxia (Adj. OR 3.81 [95% CI 1.43-10.13]) predicted stroke. Sensitivity of hemianopia or aphasia for SMs was 52.9%, with specificity of 84.1%, positive predictive value of 78.3%, and negative predictive value of 62.4%. CONCLUSIONS Hemianopia and/or aphasia with normal MCTI suggest SMs. Diffusion-weighted MRI might be discussed before rt-PA administration in patients with such a clinical pattern.
Collapse
Affiliation(s)
| | | | - Pauline Renou
- Department of Neurology, CHU de Bordeaux, Bordeaux, France
| | | | | | - Mathilde Poli
- Department of Neurology, CHU de Bordeaux, Bordeaux, France
| | | | | | - Igor Sibon
- Department of Neurology, CHU de Bordeaux, Bordeaux, France
| |
Collapse
|
17
|
Kostulas N, Larsson M, Kall TB, von Euler M, Nathanson D. Safety of thrombolysis in stroke mimics: an observational cohort study from an urban teaching hospital in Sweden. BMJ Open 2017; 7:e016311. [PMID: 29084788 PMCID: PMC5665231 DOI: 10.1136/bmjopen-2017-016311] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 08/17/2017] [Accepted: 08/22/2017] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES Acute stroke management has changed dramatically over the recent years, where a timely assessment is driven by the expanding treatment options of acute ischaemic stroke. This increases the risk in treating non-stroke patients (stroke mimics) with a possibly hazardous intravenous thrombolysis treatment (IVT). SETTING Patients of the thrombolysis registry of Södersjukhuset AB, a secondary health centre in Stockholm, were retrospectively studied to determine complications and outcome after IVT in strokes and stroke mimics. PARTICIPANTS Consecutively, 674 recruited patients from 1 January 2008 to 1 December 2013 were analysed regarding demographics and outcome at 3 months after onset of symptoms. RESULTS Ischaemic stroke was confirmed in 625 patients (93%), and 48 patients (7%) were stroke mimics. Patients with strokes were older than stroke mimics 72 (IQR: 64-81) vs 54 years (IQR 40-67), p<0.0001. Antihypertensive and antithrombotic treatment were more common in patients with stroke (p<0.0001 and p=0.006, respectively). National Institute of Health Stroke Scale did not differ at time of presentation. Excellent outcome defined as modified Rankin Scale score 0-1, at 3 months, was less common in stroke than in stroke mimics (50% vs 87.5%, p<0.0001). No stroke mimic had a symptomatic intracerebral haemorrhage. Age of less than 40 years may be a predictor for a patient to be a stroke mimic (OR: 8.7, 95% CI: 3.2 to 24.0, p<0.0001). CONCLUSIONS Stroke mimics receiving IVT had a more favourable outcome compared with patients with stroke, and showed no haemorrhagic complications. Age below 40 years may be a predictor for stroke mimics.
Collapse
Affiliation(s)
- Nikolaos Kostulas
- Depatment of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Martin Larsson
- Depatment of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Tor-Bjorn Kall
- Depatment of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Mia von Euler
- Depatment of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Karolinska Institutet Stroke Research Network, Stockholm, Sweden
| | - David Nathanson
- Depatment of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
18
|
Chompoopong P, Rostambeigi N, Kassar D, Maud A, Qureshi IA, Cruz-Flores S, Rodriguez GJ. Are We Overlooking Stroke Chameleons? A Retrospective Study on the Delayed Recognition of Stroke Patients. Cerebrovasc Dis 2017; 44:83-87. [PMID: 28511184 DOI: 10.1159/000471929] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 03/22/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE New effective recanalization therapies are currently available for acute ischemic stroke; yet a vast majority of stroke patients are left untreated. The lack of early recognition may be because often times, stroke patients present with atypical manifestations that resemble other conditions (which are referred to as "stroke chameleons"). We set to study the proportion of patients with delayed stroke recognition in a single center. METHODS We performed a retrospective analysis of a prospectively collected data over a 9-year period. All adult patients discharged with the diagnosis of ischemic stroke or transient ischemic attack (TIA) were identified and traced for their diagnosis on admission. Those cases with a diagnosis other than ischemic stroke or TIA on admission were identified as possible stroke chameleons and categorized into different groups according to the occurrence of neurological or non-neurological manifestations at presentation. RESULTS Of 2,303 cases with discharge diagnosis of ischemic stroke or TIA, 919 (39.9%) were found to be possible stroke chameleons. More than half of these patients (58.4%) presented with neurological manifestations including disorders of the somatic sensation (33%), alteration of consciousness (30%), and disorders of speech/language (11%). The remaining possible stroke chameleons had manifestations pertaining to other organ systems such as cardiopulmonary, gastrointestinal, systemic infection, trauma, and thromboembolic events elsewhere. CONCLUSIONS In our cohort, a surprisingly large percentage of possible stroke chameleons was observed. It is important to confirm our findings, study the impact on clinical outcome, and develop strategies for early stroke patient recognition.
Collapse
|
19
|
Asaithambi G, Castle AL, Sperl MA, Ravichandran J, Gupta A, Ho BM, Hanson SK. Thrombolytic treatment to stroke mimic patients via telestroke. Clin Neurol Neurosurg 2017; 153:5-7. [DOI: 10.1016/j.clineuro.2016.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/24/2016] [Accepted: 12/13/2016] [Indexed: 10/20/2022]
|
20
|
ASL and susceptibility-weighted imaging contribution to the management of acute ischaemic stroke. Insights Imaging 2016; 8:91-100. [PMID: 27822669 PMCID: PMC5265193 DOI: 10.1007/s13244-016-0529-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 09/19/2016] [Accepted: 10/03/2016] [Indexed: 12/04/2022] Open
Abstract
Abstract Magnetic resonance imaging (MRI) plays a central role in the early diagnosis of cerebral vascular events. Today, MRI is used not only for the detection of acute ischaemic lesions, but also to fine tune the diagnosis and improve patient selection for early therapeutic decision-making. In this perspective, new tools such as arterial spin labelling (ASL) and susceptibility-weighted imaging (SWI) sequences have been developed. These MRI sequences enable noninvasive assessment of brain damage, providing important diagnostic and prognostic information: evaluation of cerebral parenchymal perfusion; detection and aetiological assessment of thrombi; ruling out differential diagnoses. After a brief recall of the fundamental basis of these sequences, this article proposes an update on their current contribution to the early management of stroke victims. Teaching Points • These noninvasive sequences provide essential information for early management of acute stroke. • They can detect zones of parenchymal hypoperfusion. • Susceptibility-weighted sequences provide information on thrombus localisation and composition. • ASL can identify certain aetiologies of stroke mimics. • Post-therapeutic ASL perfusion status predicts outcome.
Collapse
|
21
|
|
22
|
Long B, Koyfman A. Clinical Mimics: An Emergency Medicine-Focused Review of Stroke Mimics. J Emerg Med 2016; 52:176-183. [PMID: 27780653 DOI: 10.1016/j.jemermed.2016.09.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Stroke is a leading cause of death and disability and most commonly presents with focal neurologic deficit within a specific vascular distribution. Several other conditions may present in a similar manner. OBJECTIVES This review provides emergency providers with an understanding of stroke mimics, use of thrombolytics in these mimics, and keys to differentiate true stroke from mimic. DISCUSSION Stroke has significant morbidity and mortality, and the American Heart Association emphasizes rapid recognition and aggressive treatment for patients with possible stroke-like symptoms, including thrombolytics. However, many conditions mimic the presentation of stroke, with up to a 31% rate of misdiagnosis, leading to potentially harmful treatment. Stroke mimics are conditions that present with stroke-like symptoms, including seizures, headaches, metabolic, infection, space-occupying lesion, neurodegenerative disorder, peripheral neuropathy, syncope, vascular disorder, and functional disorder. Factors of history and physical examination supporting stroke vs. mimic are discussed, though any sudden-onset, objective, focal neurologic deficit in a patient should be assumed acute stroke until proven otherwise. Head computed tomography noncontrast is the first-line imaging modality. Magnetic resonance imaging is the most sensitive and specific imaging modality. Neurology consultation is recommended in the majority of patients. If stroke is suspected after evaluation, shared decision-making for further management and consideration of thrombolytics is recommended. CONCLUSIONS Stroke mimics present a conundrum for emergency providers. A new focal neurologic deficit warrants rapid evaluation for stroke with neuroimaging and neurology consultation. Several mimics found on assessment may resolve with treatment.
Collapse
Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
23
|
Sivakumaran P, Gill D, Mahir G, Baheerathan A, Kar A. A Retrospective Cohort Study on the Use of Intravenous Thrombolysis in Stroke Mimics. J Stroke Cerebrovasc Dis 2016; 25:1057-1061. [PMID: 26856459 DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 01/03/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The urgency of intravenous thrombolysis in acute ischemic stroke can lead to inadvertent thrombolysis of patients with nonstroke diagnoses (stroke mimics), increasing the risk of adverse events. The objectives of this study were to compare thrombolysed acute ischemic stroke and stroke mimic cases based on demographic factors, physiological parameters, radiological findings, and clinical presentation, and to evaluate the clinical implications of thrombolysing stroke mimics. METHODS A retrospective analysis of a single-center database of all thrombolysed strokes and mimics over a period greater than 3 years. Diagnoses were confirmed by expert consensus after a review of clinical factors and imaging. Intercohort variation was assessed using Wilcoxon rank-sum or Pearson's chi-square test. RESULTS The stroke mimic cohort tended to be younger (mean age 59.9 years versus 73.7 years, P < .001) and had a lower National Institutes of Health Stroke Score at presentation (mean 5.9 points versus 6.4 points, P < .01). However, the time taken from the onset of symptoms to delivery of thrombolytic drugs was longer in the mimic cohort (mean time 170 minutes versus 138 minutes, P < .01). Any differences in blood glucose (P = .07), time taken from hospital arrival to delivery of intravenous thrombolysis (P = .57), and blood pressure on admission (systolic, P = .09 and diastolic, P = .34) were not statistically significant. No adverse events were reported in the mimic cohort. CONCLUSION Despite similarities in clinical presentation, thrombolysed stroke mimics are of a different physiological and demographic population, and are associated with fewer adverse events compared with thrombolysed acute ischemic stroke patients.
Collapse
Affiliation(s)
| | - Dipender Gill
- Imperial College Healthcare NHS Trust, London, UK; Imperial College London, London, UK.
| | - Gheed Mahir
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Arindam Kar
- Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
24
|
Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke 2016; 47:581-641. [DOI: 10.1161/str.0000000000000086] [Citation(s) in RCA: 442] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods—
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results—
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
Collapse
|
25
|
Puustjärvi V, Strbian D, Tiainen M, Curtze S, Tatlisumak T, Sairanen T. Recognition of posterior circulation stroke. Acta Neurol Scand 2015; 131:389-93. [PMID: 25402973 DOI: 10.1111/ane.12351] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Better identification and triage of acute posterior circulation (PC) stroke patients is needed as the PC ischemic stroke (IS) patients may be allowed longer thrombolysis window than anterior circulation (AC) IS patients and PC patients with hemorrhagic stroke (ICH) may require care in a neurosurgical unit possibly remote from stroke unit. MATERIALS AND METHODS Consecutive stroke patients treated at a tertiary center with thrombolysis (100% for IS) and/or comprehensive stroke unit care. RESULTS Altogether, 1641 patients had AC (75%) and 553 PC strokes. The PC-IS patients were younger (65 vs 70), had less often prior hypertension (51 vs 61%), and were twice more often on warfarin. They presented 3.5 times more often with seizure, vomited five times more often, had headache twice as often, and required intubation 2 to 3 times more often despite equal NIHSS (9 vs 8) or GCS (15 both) scores with AC-IS patients. Among PC patients, IS (n = 190) associated with younger age, prior atrial fibrillation (AF) in 25% and dyslipidemia in ~40%. One-third of PC-ICH patients (n = 363) had headache and vomited at the onset. PC-ICH patients had BP median of 177/92 mmHg and blood glucose 7.4 mmol/l on ER arrival. Warfarin use was twice as common in PC-ICH. CONCLUSIONS Despite being of typical age for multiple cardiovascular conditions the PC-ICH patients less often have a previous history of AF or dyslipidemia than IS patients do. The vomiting PC-ICH patient with hypertensive BP values often has headache and a red flag for hemorrhage is warfarin treatment.
Collapse
Affiliation(s)
- V. Puustjärvi
- Faculty of Medicine; University of Helsinki; Helsinki Finland
| | - D. Strbian
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - M. Tiainen
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - S. Curtze
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - T. Tatlisumak
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| | - T. Sairanen
- Department of Neurology; Helsinki University Central Hospital; Helsinki Finland
| |
Collapse
|
26
|
Abstract
Efforts are underway to develop novel platforms for stroke diagnosis to meet the criteria for effective treatment within the narrow time window mandated by the FDA-approved therapeutic (<3 h). Blood-based biomarkers could be used for rapid stroke diagnosis and coupled with new analytical tools, could serve as an attractive platform for managing stroke-related diseases. In this review, we will discuss the physiological processes associated with stroke and current diagnostic tools as well as their associated shortcomings. We will then review information on blood-based biomarkers and various detection technologies. In particular, point of care testing that permits small blood volumes required for the analysis and rapid turn-around time measurements of multiple markers will be presented.
Collapse
|
27
|
Nguyen PL, Chang JJ. Stroke Mimics and Acute Stroke Evaluation: Clinical Differentiation and Complications after Intravenous Tissue Plasminogen Activator. J Emerg Med 2015; 49:244-52. [PMID: 25802155 DOI: 10.1016/j.jemermed.2014.12.072] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 12/04/2014] [Accepted: 12/22/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND Intravenous tissue-plasminogen activator remains the only U.S. Food and Drug Administration-approved treatment for acute ischemic stroke. Timely administration of fibrinolysis is balanced with the need for accurate diagnosis. Stroke mimics represent a heterogeneous group of patients presenting with acute-onset focal neurological deficits. If these patients arrive within the extended time window for acute stroke treatment, these stroke mimics may erroneously receive fibrinolytics. OBJECTIVE This review explores the literature and presents strategies for differentiating stroke mimics. DISCUSSION Clinical outcome in stroke mimics receiving fibrinolytics is overwhelmingly better than their stroke counterparts. However, the risk of symptomatic intracranial hemorrhage remains a real but rare possibility. Certain presenting complaints and epidemiological risk factors may help differentiate strokes from stroke mimics; however, detection of stroke often depends on presence of posterior vs. anterior circulation strokes. Availability of imaging modalities also assists in diagnosing stroke mimics, with magnetic resonance imaging offering the most sensitivity and specificity. CONCLUSION Stroke mimics remain a heterogeneous entity that is difficult to identify. All studies in the literature report that stroke mimics treated with intravenous fibrinolysis have better clinical outcome than their stroke counterparts. Although symptomatic intracranial hemorrhage remains a real threat, literature searches have identified only two cases of symptomatic intracranial hemorrhage in stroke mimics treated with fibrinolytics.
Collapse
Affiliation(s)
- Peggy L Nguyen
- Department of Neurology, University of Southern California, Los Angeles, California
| | - Jason J Chang
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| |
Collapse
|
28
|
Tsivgoulis G, Zand R, Katsanos AH, Goyal N, Uchino K, Chang J, Dardiotis E, Putaala J, Alexandrov AW, Malkoff MD, Alexandrov AV. Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis. Stroke 2015; 46:1281-7. [PMID: 25791717 DOI: 10.1161/strokeaha.115.009012] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 02/25/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Shortening door-to-needle time may lead to inadvertent intravenous thrombolysis (IVT) administration in stroke mimics (SMs). We sought to determine the safety of IVT in SMs using prospective, single-center data and by conducting a comprehensive meta-analysis of reported case-series. METHODS We prospectively analyzed consecutive IVT-treated patients during a 5-year period at a tertiary care stroke center. A systematic review and meta-analysis of case-series reporting safety of IVT in SMs and confirmed acute ischemic stroke were conducted. Symptomatic intracerebral hemorrhage was defined as imaging evidence of ICH with an National Institutes of Health Stroke scale increase of ≥4 points. Favorable functional outcome at hospital discharge was defined as a modified Rankin Scale score of 0 to 1. RESULTS Of 516 consecutive IVT patients at our tertiary care center (50% men; mean age, 60±14 years; median National Institutes of Health Stroke scale, 11; range, 3-22), SMs comprised 75 cases. Symptomatic intracerebral hemorrhage occurred in 1 patient, whereas we documented no cases of orolingual edema or major extracranial hemorrhagic complications. In meta-analysis of 9 studies (8942 IVT-treated patients), the pooled rates of symptomatic intracerebral hemorrhage and orolingual edema among 392 patients with SM treated with IVT were 0.5% (95% confidence interval, 0%-2%) and 0.3% (95% confidence interval, 0%-2%), respectively. Patients with SM were found to have a significantly lower risk for symptomatic intracerebral hemorrhage compared with patients with acute ischemic stroke (risk ratio=0.33; 95% confidence interval, 0.14-0.77; P=0.010), with no evidence of heterogeneity or publication bias. Favorable functional outcome was almost 3-fold higher in patients with SM in comparison with patients with acute ischemic stroke (risk ratio=2.78; 95% confidence interval, 2.07-3.73; P<0.00001). CONCLUSIONS Our prospective, single-center experience coupled with the findings of the comprehensive meta-analysis underscores the safety of IVT in SM.
Collapse
Affiliation(s)
- Georgios Tsivgoulis
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Ramin Zand
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Aristeidis H Katsanos
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Nitin Goyal
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Ken Uchino
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Jason Chang
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Efthimios Dardiotis
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Jukka Putaala
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Anne W Alexandrov
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Marc D Malkoff
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Andrei V Alexandrov
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| |
Collapse
|
29
|
Kim WJ, Paik NJ. Lesion localization of global aphasia without hemiparesis by overlapping of the brain magnetic resonance images. Neural Regen Res 2015; 9:2081-6. [PMID: 25657725 PMCID: PMC4316473 DOI: 10.4103/1673-5374.147935] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2014] [Indexed: 11/10/2022] Open
Abstract
Global aphasia without hemiparesis is a striking stroke syndrome involving language impairment without the typically manifested contralateral hemiparesis, which is usually seen in patients with global aphasia following large left perisylvian lesions. The objective of this study is to elucidate the specific areas for lesion localization of global aphasia without hemiparesis by retrospectively studying the brain magnetic resonance images of six patients with global aphasia without hemiparesis to define global aphasia without hemiparesis-related stroke lesions before overlapping the images to visualize the most overlapped area. Talairach coordinates for the most overlapped areas were converted to corresponding anatomical regions. Lesions where the images of more than three patients overlapped were considered significant. The overlapped global aphasia without hemiparesis related stroke lesions of six patients revealed that the significantly involved anatomical lesions were as follows: frontal lobe, sub-gyral, sub-lobar, extra-nuclear, corpus callosum, and inferior frontal gyrus, while caudate, claustrum, middle frontal gyrus, limbic lobe, temporal lobe, superior temporal gyrus, uncus, anterior cingulate, parahippocampal, amygdala, and subcallosal gyrus were seen less significantly involved. This study is the first to demonstrate the heterogeneous anatomical involvement in global aphasia without hemiparesis by overlapping of the brain magnetic resonance images.
Collapse
Affiliation(s)
- Woo Jin Kim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea ; Department of Physical Medicine and Rehabilitation, Haeundae Paik Hospital, Inje University of Medicine, Busan, South Korea
| | - Nam-Jong Paik
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea ; Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, South Korea
| |
Collapse
|
30
|
Stecker MM, Michel K, Antaky K, Wolin A, Koyfman F. Characteristics of the stroke alert process in a general Hospital. Surg Neurol Int 2015; 6:5. [PMID: 25657858 PMCID: PMC4310046 DOI: 10.4103/2152-7806.149387] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 09/23/2014] [Indexed: 12/16/2022] Open
Abstract
Background: The organized stroke alert is critical in quickly evaluating and treating patients with acute stroke. The purpose of this paper was to further understand how this process functions in a moderate sized general hospital by exploring the effects of patient location and time of day on the pace of evaluation and the eventual outcome of evaluation. Methods: Retrospective chart review. Results: The rate of stroke alerts depended on the time of day and patient location. There was a low probability (41%) that the eventual diagnosis was stroke after a stroke alert, but there was no effect of diagnosis on the pace of evaluation. The time between stroke alert and a computed tomography (CT) scan being read was shortest for patients in the emergency room (ER) and longer for patients in the intensive care unit (ICU) or medical/surgical floors. Patients evaluated on medical/surgical floors were less likely to receive tissue plasminogen activator (tPA) than those evaluated in the ER, even though the comorbidities were similar. This may be due to the greater severity of the comorbidities in patients who were already admitted to the hospital. Conclusion: The rate of tPA administration was lower for stroke alerts called from medical/surgical floors than from the ER. Stroke alerts were most frequent in late afternoon.
Collapse
Affiliation(s)
- Mark M Stecker
- Department of Neuroscience, Winthrop University Hospital, Mineola, NY 11501, USA
| | - Kathleen Michel
- Department of Neuroscience, Winthrop University Hospital, Mineola, NY 11501, USA
| | - Karin Antaky
- Department of Neuroscience, Winthrop University Hospital, Mineola, NY 11501, USA
| | - Adam Wolin
- Department of Neuroscience, Winthrop University Hospital, Mineola, NY 11501, USA
| | - Feliks Koyfman
- Department of Neuroscience, Winthrop University Hospital, Mineola, NY 11501, USA
| |
Collapse
|
31
|
MR screening of candidates for thrombolysis: How to identify stroke mimics? J Neuroradiol 2014; 41:283-95. [PMID: 25451670 DOI: 10.1016/j.neurad.2014.05.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 05/24/2014] [Accepted: 05/26/2014] [Indexed: 11/21/2022]
Abstract
Stroke mimics account for up to a third of suspected strokes. The main causes are epileptic deficit, migraine aura, hypoglycemia, and functional disorders. Accurate recognition of stroke mimics is important for adequate identification of candidates for thrombolysis. This decreases the number of unnecessary treatments and invasive vascular investigations. Correctly identifying the cause of symptoms also avoids delaying proper care. Therefore, this pictorial review focuses on what the radiologist should know about the most common MRI patterns of stroke mimics in the first hours after onset of symptoms. The issues linked to the accurate diagnosis of stroke mimics in the management of candidates for thrombolysis will be discussed.
Collapse
|
32
|
Lewandowski C, Mays-Wilson K, Miller J, Penstone P, Miller DJ, Bakoulas K, Mitsias P. Safety and outcomes in stroke mimics after intravenous tissue plasminogen activator administration: a single-center experience. J Stroke Cerebrovasc Dis 2014; 24:48-52. [PMID: 25440358 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.048] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 06/17/2014] [Accepted: 07/27/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Patients with symptoms that impersonate a stroke but are later found to have an alternate diagnosis are termed stroke mimics. Stroke mimics treated with intravenous (IV) tissue plasminogen activator (t-PA) are exposed to hemorrhagic complications without benefit. The objective of this study is to describe the characteristics, safety, and outcomes of stroke mimic patients treated with t-PA within 4.5 hours. METHODS All patients hospitalized after IV t-PA treatment at a tertiary care hospital and primary stroke center from January 2008 through December 2011 were reviewed. Stroke mimics were determined by review of clinical and imaging findings. Stroke mimics are described and compared with acute ischemic stroke patients for demographics, clinical characteristics, and bleeding complications. RESULTS We identified 38 stroke mimic (12%) and 285 ischemic stroke (88%) t-PA-treated patients. Compared with ischemic stroke patients, mimic patients were younger, more often female, and reported a history of stroke more often. There were no differences in race, baseline stroke scale, or onset to treatment time. There were no intracerebral hemorrhages or deaths in the mimic patients but there were 2 systemic hemorrhages (5.2%). CONCLUSIONS Treatment of mimic patients with IV t-PA appears to be safe in this cohort. Concern for intracerebral hemorrhage in mimic patients need not dissuade clinicians from administering t-PA when significant concern for ischemic etiology exists.
Collapse
Affiliation(s)
| | | | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan.
| | | | - Daniel J Miller
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan
| | | | | |
Collapse
|
33
|
Chapman SN, Mehndiratta P, Johansen MC, McMurry TL, Johnston KC, Southerland AM. Current perspectives on the use of intravenous recombinant tissue plasminogen activator (tPA) for treatment of acute ischemic stroke. Vasc Health Risk Manag 2014; 10:75-87. [PMID: 24591838 PMCID: PMC3938499 DOI: 10.2147/vhrm.s39213] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In 1995, the NINDS (National Institute of Neurological Disorders and Stroke) tPA (tissue plasminogen activator) Stroke Study Group published the results of a large multicenter clinical trial demonstrating efficacy of intravenous tPA by revealing a 30% relative risk reduction (absolute risk reduction 11%-15%) compared with placebo at 90 days in the likelihood of having minimal or no disability. Since approval in 1996, tPA remains the only drug treatment for acute ischemic stroke approved by the US Food and Drug Administration. Over the years, an abundance of research and clinical data has supported the safe and efficacious use of intravenous tPA in all eligible patients. Despite such supporting data, it remains substantially underutilized. Challenges to the utilization of tPA include narrow eligibility and treatment windows, risk of symptomatic intracerebral hemorrhage, perceived lack of efficacy in certain high-risk subgroups, and a limited pool of neurological and stroke expertise in the community. With recent US census data suggesting annual stroke incidence will more than double by 2050, better education and consensus among both the medical and lay public are necessary to optimize the use of tPA for all eligible stroke patients. Ongoing and future research should continue to improve upon the efficacy of tPA through more rapid stroke diagnosis and treatment, refinement of advanced neuroimaging and stroke biomarkers, and successful demonstration of alternative means of reperfusion.
Collapse
Affiliation(s)
- Sherita N Chapman
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - Prachi Mehndiratta
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | | | - Timothy L McMurry
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Karen C Johnston
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Andrew M Southerland
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
34
|
Raymond CE, Aggarwal B, Schoenhagen P, Kralovic DM, Kormos K, Holloway D, Menon V. Prevalence and factors associated with false positive suspicion of acute aortic syndrome: experience in a patient population transferred to a specialized aortic treatment center. Cardiovasc Diagn Ther 2014; 3:196-204. [PMID: 24400203 DOI: 10.3978/j.issn.2223-3652.2013.12.06] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 11/11/2013] [Indexed: 11/14/2022]
Abstract
STUDY OBJECTIVE Acute aortic syndrome (AAS) is a medical emergency that requires prompt diagnosis and treatment at specialized centers. We sought to determine the frequency and etiology of false positive activation of a regional AAS network in a patient population emergently transferred for suspected AAS. METHODS We evaluated 150 consecutive patients transferred from community emergency departments directly to our Cardiac Intensive Care Unit (CICU) with a diagnosis of suspected AAS between March, 2010 and August, 2011. A final diagnosis of confirmed acute Type A, acute Type B dissection, and false positive suspicion of dissection was made in 63 (42%), 70 (46.7%) and 17 (11.3%) patients respectively. RESULTS Of the 17 false positive transfers, ten (58.8%) were suspected Type A dissection and seven (41.2%) were suspected Type B dissection. The initial hospital diagnosis in 15 (88.2%) patients was made by a computed tomography (CT) scan and 10 (66.6%) of these patients required repeat imaging with an ECG-synchronized CT to definitively rule out AAS. Five (29.4%) patients had prior history of open or endovascular aortic repair. Overall in-hospital mortality was 9.3%. CONCLUSIONS The diagnosis of AAS is confirmed in most patients emergently transferred for suspected AAS. False positive activation in this setting is driven primarily by uncertainty secondary to motion-artifact of the ascending aorta and the presence of complex anatomy following prior aortic intervention. Network-wide standardization of imaging strategies, and improved sharing of imaging may further improve triage of this complex patient population.
Collapse
Affiliation(s)
- Chad E Raymond
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bhuvnesh Aggarwal
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul Schoenhagen
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Damon M Kralovic
- Emergency Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kristopher Kormos
- Emergency Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - David Holloway
- Emergency Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Venu Menon
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
35
|
Affiliation(s)
- Daniel J Boulter
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Pamela W Schaefer
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Boston, MA.
| |
Collapse
|
36
|
Kose A, Inal T, Armagan E, Kıyak R, Demir AB. Conditions that Mimic Stroke in Elderly Patients Admitted to the Emergency Department. J Stroke Cerebrovasc Dis 2013; 22:e522-7. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.05.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 05/09/2013] [Accepted: 05/26/2013] [Indexed: 10/26/2022] Open
|
37
|
|
38
|
Stroke mimics under the drip-and-ship paradigm. J Stroke Cerebrovasc Dis 2013; 23:844-9. [PMID: 23954600 DOI: 10.1016/j.jstrokecerebrovasdis.2013.07.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 06/28/2013] [Accepted: 07/07/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. We hypothesized that a higher rate of stroke mimics (SM) among AIS treated in nonspecialized stroke centers that are transferred to comprehensive centers is responsible for such outcomes. METHODS Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over 1 academic year (July 1, 2011 to June 30, 2012). Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge disposition was collected. We identified those patients who were treated at a facility and then transferred to the tertiary center (ie, drip-and-ship paradigm). In addition to comparative and adjusted analysis to identify predictors for SM, a stratified analysis by the drip-and-ship status was performed. RESULTS One hundred twenty patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = .0003) and more likely to harbor psychiatric diagnoses (45% versus 9%; P ≤ .0001). Eighteen of 20 SM patients (90%) had the drip-and-ship treatment paradigm compared with 65% of those with AIS (P = .02). None of the SM had hemorrhagic complications, and all were discharged to home. Predictors of SM on adjusted analysis included the drip-and-ship paradigm (odds ratio [OR] 12.8, 95% confidence interval [CI] 1.78, 92.1) and history of any psychiatric illness (OR 12.08; 95% CI 3.14, 46.4). Eighteen of 83 drip-and-ship patients (21.7%) were diagnosed with SM compared with 2 of 37 patients (5.4%) presented directly to the hub hospital (P = .02). CONCLUSION The drip-and-ship paradigm and any psychiatric history predict the diagnosis of SM. None of the SM had thrombolysis-related complications, and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment for AIS.
Collapse
|
39
|
|
40
|
Ringelstein EB, Chamorro A, Kaste M, Langhorne P, Leys D, Lyrer P, Thijs V, Thomassen L, Toni D. European Stroke Organisation Recommendations to Establish a Stroke Unit and Stroke Center. Stroke 2013; 44:828-40. [DOI: 10.1161/strokeaha.112.670430] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- E. Bernd Ringelstein
- From the Department of Neurology, University Hospital, Münster, Germany (E.B.R.); Department of Clinical Neurosciences, University of Barcelona, Hospital Clinic, Barcelona, Spain (A.C.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (M.K.); Academic Section of Geriatric Medicine, University Hospital, Glasgow, United Kingdom (P.La.); Department of Neurology, University Hospital, Lille, France (D.L.); Department of Neurology, University Hospital, Basel, Switzerland
| | - Angel Chamorro
- From the Department of Neurology, University Hospital, Münster, Germany (E.B.R.); Department of Clinical Neurosciences, University of Barcelona, Hospital Clinic, Barcelona, Spain (A.C.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (M.K.); Academic Section of Geriatric Medicine, University Hospital, Glasgow, United Kingdom (P.La.); Department of Neurology, University Hospital, Lille, France (D.L.); Department of Neurology, University Hospital, Basel, Switzerland
| | - Markku Kaste
- From the Department of Neurology, University Hospital, Münster, Germany (E.B.R.); Department of Clinical Neurosciences, University of Barcelona, Hospital Clinic, Barcelona, Spain (A.C.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (M.K.); Academic Section of Geriatric Medicine, University Hospital, Glasgow, United Kingdom (P.La.); Department of Neurology, University Hospital, Lille, France (D.L.); Department of Neurology, University Hospital, Basel, Switzerland
| | - Peter Langhorne
- From the Department of Neurology, University Hospital, Münster, Germany (E.B.R.); Department of Clinical Neurosciences, University of Barcelona, Hospital Clinic, Barcelona, Spain (A.C.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (M.K.); Academic Section of Geriatric Medicine, University Hospital, Glasgow, United Kingdom (P.La.); Department of Neurology, University Hospital, Lille, France (D.L.); Department of Neurology, University Hospital, Basel, Switzerland
| | - Didier Leys
- From the Department of Neurology, University Hospital, Münster, Germany (E.B.R.); Department of Clinical Neurosciences, University of Barcelona, Hospital Clinic, Barcelona, Spain (A.C.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (M.K.); Academic Section of Geriatric Medicine, University Hospital, Glasgow, United Kingdom (P.La.); Department of Neurology, University Hospital, Lille, France (D.L.); Department of Neurology, University Hospital, Basel, Switzerland
| | - Philippe Lyrer
- From the Department of Neurology, University Hospital, Münster, Germany (E.B.R.); Department of Clinical Neurosciences, University of Barcelona, Hospital Clinic, Barcelona, Spain (A.C.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (M.K.); Academic Section of Geriatric Medicine, University Hospital, Glasgow, United Kingdom (P.La.); Department of Neurology, University Hospital, Lille, France (D.L.); Department of Neurology, University Hospital, Basel, Switzerland
| | - Vincent Thijs
- From the Department of Neurology, University Hospital, Münster, Germany (E.B.R.); Department of Clinical Neurosciences, University of Barcelona, Hospital Clinic, Barcelona, Spain (A.C.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (M.K.); Academic Section of Geriatric Medicine, University Hospital, Glasgow, United Kingdom (P.La.); Department of Neurology, University Hospital, Lille, France (D.L.); Department of Neurology, University Hospital, Basel, Switzerland
| | - Lars Thomassen
- From the Department of Neurology, University Hospital, Münster, Germany (E.B.R.); Department of Clinical Neurosciences, University of Barcelona, Hospital Clinic, Barcelona, Spain (A.C.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (M.K.); Academic Section of Geriatric Medicine, University Hospital, Glasgow, United Kingdom (P.La.); Department of Neurology, University Hospital, Lille, France (D.L.); Department of Neurology, University Hospital, Basel, Switzerland
| | - Danilo Toni
- From the Department of Neurology, University Hospital, Münster, Germany (E.B.R.); Department of Clinical Neurosciences, University of Barcelona, Hospital Clinic, Barcelona, Spain (A.C.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (M.K.); Academic Section of Geriatric Medicine, University Hospital, Glasgow, United Kingdom (P.La.); Department of Neurology, University Hospital, Lille, France (D.L.); Department of Neurology, University Hospital, Basel, Switzerland
| |
Collapse
|
41
|
Zinkstok SM, Engelter ST, Gensicke H, Lyrer PA, Ringleb PA, Artto V, Putaala J, Haapaniemi E, Tatlisumak T, Chen Y, Leys D, Sarikaya H, Michel P, Odier C, Berrouschot J, Arnold M, Heldner MR, Zini A, Fioravanti V, Padjen V, Beslac-Bumbasirevic L, Pezzini A, Roos YB, Nederkoorn PJ. Safety of thrombolysis in stroke mimics: results from a multicenter cohort study. Stroke 2013; 44:1080-4. [PMID: 23444310 DOI: 10.1161/strokeaha.111.000126] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis for acute ischemic stroke is beneficial within 4.5 hours of symptom onset, but the effect rapidly decreases over time, necessitating quick diagnostic in-hospital work-up. Initial time strain occasionally results in treatment of patients with an alternate diagnosis (stroke mimics). We investigated whether intravenous thrombolysis is safe in these patients. METHODS In this multicenter observational cohort study containing 5581 consecutive patients treated with intravenous thrombolysis, we determined the frequency and the clinical characteristics of stroke mimics. For safety, we compared the symptomatic intracranial hemorrhage (European Cooperative Acute Stroke Study II [ECASS-II] definition) rate of stroke mimics with ischemic strokes. RESULTS One hundred stroke mimics were identified, resulting in a frequency of 1.8% (95% confidence interval, 1.5-2.2). Patients with a stroke mimic were younger, more often female, and had fewer risk factors except smoking and previous stroke or transient ischemic attack. The symptomatic intracranial hemorrhage rate in stroke mimics was 1.0% (95% confidence interval, 0.0-5.0) compared with 7.9% (95% confidence interval, 7.2-8.7) in ischemic strokes. CONCLUSIONS In experienced stroke centers, among patients treated with intravenous thrombolysis, only a few had a final diagnosis other than stroke. The complication rate in these stroke mimics was low.
Collapse
Affiliation(s)
- Sanne M Zinkstok
- Department of Neurology, Academic Medical Center University of Amsterdam, Amsterdam, the Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Aseptic meningoencephalitis mimicking transient ischaemic attacks. Infection 2013; 41:485-91. [DOI: 10.1007/s15010-012-0397-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 12/22/2012] [Indexed: 11/26/2022]
|
43
|
Ford AL, Williams JA, Spencer M, McCammon C, Khoury N, Sampson TR, Panagos P, Lee JM. Reducing door-to-needle times using Toyota's lean manufacturing principles and value stream analysis. Stroke 2012; 43:3395-8. [PMID: 23138440 DOI: 10.1161/strokeaha.112.670687] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Earlier tissue-type plasminogen activator (tPA) treatment for acute ischemic stroke increases efficacy, prompting national efforts to reduce door-to-needle times. We used lean process improvement methodology to develop a streamlined intravenous tPA protocol. METHODS In early 2011, a multidisciplinary team analyzed the steps required to treat patients with acute ischemic stroke with intravenous tPA using value stream analysis (VSA). We directly compared the tPA-treated patients in the "pre-VSA" epoch with the "post-VSA" epoch with regard to baseline characteristics, protocol metrics, and clinical outcomes. RESULTS The VSA revealed several tPA protocol inefficiencies: routing of patients to room, then to CT, then back to the room; serial processing of workflow; and delays in waiting for laboratory results. On March 1, 2011, a new protocol incorporated changes to minimize delays: routing patients directly to head CT before the patient room, using parallel process workflow, and implementing point-of-care laboratories. In the pre and post-VSA epochs, 132 and 87 patients were treated with intravenous tPA, respectively. Compared with pre-VSA, door-to-needle times and percent of patients treated ≤60 minutes from hospital arrival were improved in the post-VSA epoch: 60 minutes versus 39 minutes (P<0.0001) and 52% versus 78% (P<0.0001), respectively, with no change in symptomatic hemorrhage rate. CONCLUSIONS Lean process improvement methodology can expedite time-dependent stroke care without compromising safety.
Collapse
Affiliation(s)
- Andria L Ford
- Washington University School of Medicine, Department of Neurology, and Emergency Department, Neurology and Neursurgery Center, Barnes-Jewish Hospital, 600 South Euclid Avenue, Box 8111, St Louis, MO 63110, USA
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Durston W. Stroke Mimics and Intravenous Thrombolysis. Ann Emerg Med 2012; 60:246; author reply 246-7. [DOI: 10.1016/j.annemergmed.2012.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 01/29/2012] [Accepted: 02/01/2012] [Indexed: 11/30/2022]
|
45
|
Pope JV, Edlow JA. Avoiding misdiagnosis in patients with neurological emergencies. Emerg Med Int 2012; 2012:949275. [PMID: 22888439 PMCID: PMC3410308 DOI: 10.1155/2012/949275] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 06/11/2012] [Indexed: 12/19/2022] Open
Abstract
Approximately 5% of patients presenting to emergency departments have neurological symptoms. The most common symptoms or diagnoses include headache, dizziness, back pain, weakness, and seizure disorder. Little is known about the actual misdiagnosis of these patients, which can have disastrous consequences for both the patients and the physicians. This paper reviews the existing literature about the misdiagnosis of neurological emergencies and analyzes the reason behind the misdiagnosis by specific presenting complaint. Our goal is to help emergency physicians and other providers reduce diagnostic error, understand how these errors are made, and improve patient care.
Collapse
Affiliation(s)
- Jennifer V. Pope
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | | |
Collapse
|
46
|
Thrombolytic Use in Transient Ischemic Attack and Stroke Mimics. Ann Emerg Med 2012; 59:336-7; author reply 337-8. [DOI: 10.1016/j.annemergmed.2011.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 10/24/2011] [Accepted: 10/25/2011] [Indexed: 11/20/2022]
|
47
|
Guerrero WR, Dababneh H, Eisenschenk S. The role of perfusion CT in identifying stroke mimics in the emergency room: a case of status epilepticus presenting with perfusion CT alterations. Int J Emerg Med 2012; 5:4. [PMID: 22264341 PMCID: PMC3271969 DOI: 10.1186/1865-1380-5-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 01/20/2012] [Indexed: 05/26/2023] Open
Abstract
Emergency medicine physicians are often faced with the challenging task of differentiating true acute ischemic strokes from stroke mimics. We present a case that was initially diagnosed as acute stroke. However, perfusion CT and EEG eventually led to the final diagnosis of status epilepticus. This case further asserts the role of CT perfusion in the evaluation of patients with stroke mimics in the emergency room setting.
Collapse
Affiliation(s)
- Waldo R Guerrero
- Department of Neurology, College of Medicine, University of Florida, 1601 Archer Road Gainesville, 32610-0236 FL, USA.
| | | | | |
Collapse
|
48
|
Guillan M, Alonso-Canovas A, Gonzalez-Valcarcel J, Garcia Barragan N, Garcia Caldentey J, Hernandez-Medrano I, DeFelipe-Mimbrera A, Sanchez-Gonzalez V, Terecoasa E, Alonso de Leciñana M, Masjuan J. Stroke Mimics Treated with Thrombolysis: Further Evidence on Safety and Distinctive Clinical Features. Cerebrovasc Dis 2012; 34:115-20. [DOI: 10.1159/000339676] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 05/15/2012] [Indexed: 11/19/2022] Open
|
49
|
|