Conditions that Mimic Stroke in Elderly Patients Admitted to the Emergency Department

Thrombotic thrombocytopenic purpura presenting as stroke mimics with normal diffusion-weighted MRI

BACKGROUND

Thrombotic thrombocytopenic purpura (TTP) is a rare and fatal thrombotic microangiopathy-based hematologic disease. Stroke has been reported as atypical neurological manifestations of TTP in some cases.

CASE PRESENTATION

A 65-year-old male presented with typical acute ischemic stroke symptoms including sudden-onset dysarthria, right-sided facial paralysis and hemiplegia. However, his CT and MRI scans were negative without showing any new ischemic lesions. He was diagnosed with TTP with severe thrombocytopenia, mild anemia, increased LDH, and low ADAMTS-13 activity. The symptoms and positive signs were rapidly resolved after administrating the plasma exchange therapy.

CONCLUSION

Clinicians should consider the possibility of TTP when a patient presents with acute stroke-like symptoms and thrombocytopenia, especially in an emergency room, either with or without new stroke lesions on the brain CT and MRI.

Denial of Cerebrovascular Events in a National Clinical Quality Registry for Stroke: A Retrospective Cohort Study

OBJECTIVES

To investigate cerebrovascular event (CVE) denials reported by registered patients to the Australian Stroke Clinical Registry, and to examine the factors associated with CVE denial.

MATERIAL AND METHODS

CVE denials reported from January 1, 2017 to June 30, 2018 were followed up with hospitals to verify their discharge diagnosis. CVE denials were compared with all non-CVE denial registrants and a 5% random sub-sample of non-CVE deniers according to patient and clinical characteristics, quality of care indicators and health outcomes. Multilevel, multivariable logistic regression models were used. Factors explored were age, sex, stroke severity, type of stroke, treatment in a stroke unit, length of stay and discharge destination. Level was defined as hospital.

RESULTS

Overall, 339/23,830 (<2%) CVE denials were reported during the 18-month period. Hospitals confirmed 117 (61%) of CVE denials as a verified diagnosis of stroke or transient ischaemic attack (TIA). Compared to non-CVE deniers, CVE deniers were younger, had a shorter median length of stay (four days versus one day) and were more likely to be diagnosed with a TIA (64%) compared to the other types of stroke (11% intracerebral haemorrhage; 20% ischaemic; 5% undetermined).

CONCLUSION

Very few patients denied their CVE, with the majority of denials subsequently confirmed as eligible for registry inclusion. Diagnosis of a TIA and shorter length of stay were associated with CVE denial. These findings provide evidence that very few cases are incorrectly entered into a national registry, and highlight the characteristics of those unlikely to accept their clinical diagnosis where further education of diagnosis may be needed.

Value of Vascular and Non-Vascular Pattern on Computed Tomography Perfusion in Patients With Acute Isolated Aphasia

Background and Purpose:

Acute onset aphasia may be due to stroke but also to other causes, which are commonly referred to as stroke mimics. We hypothesized that, in patients with acute isolated aphasia, distinct brain perfusion patterns are related to the cause and the clinical outcome. Herein, we analyzed the prognostic yield and the diagnostic usefulness of computed tomography perfusion (CTP) in patients with acute isolated aphasia.

Methods:

From a single-center registry, we selected a cohort of 154 patients presenting with acute isolated aphasia who had a whole-brain CTP study available. We collected the main clinical and radiological data. We categorized brain perfusion studies on CTP into vascular and nonvascular perfusion patterns and the cause of aphasia as ischemic stroke, transient ischemic attack, stroke mimic, and undetermined cause. The primary clinical outcome was the persistence of aphasia at discharge. We analyzed the sensitivity, specificity, positive and negative predictive values of perfusion patterns to predict complete clinical recovery and ischemic stroke on follow-up imaging.

Results:

The cause of aphasia was an ischemic stroke in 58 patients (38%), transient ischemic attack in 3 (2%), stroke mimic in 68 (44%), and undetermined in 25 (16%). CTP showed vascular and nonvascular perfusion pattern in 62 (40%) and 92 (60%) patients, respectively. Overall, complete recovery occurred in 116 patients (75%). A nonvascular perfusion pattern predicted complete recovery (sensitivity 75.9%, specificity 89.5%, positive predictive value 95.7%, and negative predictive value 54.8%), and a vascular perfusion pattern was highly predictive of ischemic stroke (sensitivity 94.8%, specificity 92.7%, positive predictive value 88.7%, and negative predictive value 96.7%). The 3 patients with ischemic stroke without a vascular perfusion pattern fully recovered at discharge.

Conclusions:

CTP has prognostic value in the workup of patients with acute isolated aphasia. A nonvascular pattern is associated with higher odds of full recovery and may prompt the search for alternative causes of the symptoms.

An unusual presentation of hemiparesis: Rapidly progressing Streptococcal pneumoniae meningitis secondary to acute mastoiditis

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Acute bacterial meningitis should be included in the differential diagnosis when considering stroke mimics.

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Potential for rapid progression highlights the importance of hourly neurological exams and early intervention.

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Antimicrobials, steroids, and myringotomy with tympanostomy tube are effective interventions in treating meningitis secondary to mastoiditis.

A sixty-three year-old male who arrived to our emergency department with signs and symptoms of an acute left middle cerebral artery cerebrovascular accident. Initial neurovascular imaging failed to demonstrate any abnormalities that explained his symptoms. His neurologic status rapidly deteriorated in conjunction with the development of severe sepsis. The patient required endotracheal intubation and was transferred to our intensive care unit. After an extensive diagnostic work-up, the etiology of his condition was determined to be due to bacterial meningitis originating from acute mastoiditis. Cultures of cerebrospinal fluid and peripheral blood grew Streptococcus pneumoniae. The patient improved with intravenous antimicrobials, intravenous dexamethasone and a left sided myringotomy with tympanostomy tube. The patient made a complete neurological recovery following this treatment.

Stroke Referrals from Nursing Homes: High Rate of Mimics and Late Presentation

BACKGROUND

Stroke has become a treatable condition with increasing evidence of treatment benefits in older people. However, stroke mimics in geriatric patients are especially prevalent, causing incorrect suspicion and consecutive burden to patients and emergency room resources. We therefore examined the dimension of this problem by investigating emergency room admissions from nursing homes for suspected stroke.

METHODS

We performed a retrospective cohort study of all nursing home residents who were admitted to the neurological emergency room of our primary and tertiary care university hospital between 2013 and 2015. Patients were further divided into those with confirmed stroke and stroke mimics after diagnostic stroke work-up.

RESULTS

Of 419 nursing home patients referred to the emergency room, nearly one third had suspected stroke (n = 126; mean age: 78 ± 14 years, polypharmacy rate: 77%). Of those, 43 (34%) had a confirmed stroke (ischaemic: n = 34; haemorrhagic: n = 9) and 83 (66%) had stroke mimics after diagnostic work-up. Only one patient underwent intravenous thrombolysis, followed by mechanical thrombectomy for middle cerebral artery occlusion. Prehospital delay (47%) and multimorbidity-associated contraindications (27%) were the main reasons for withholding recanalization therapy. Among the stroke-mimicking conditions, infectious diseases (24%) and epileptic seizures (20%) were the most frequent. Multivariate analysis identified focal deficits (OR 16.6, 95% CI 4.3-64.0), atrial fibrillation (OR 3.9, 95% CI 1.5-10.5) and previous stroke (OR 3.2, 95% CI 1.2-8.9) as indicators that were associated with stroke.

CONCLUSIONS

In our region, nursing home referrals for suspected stroke have a high false positive rate and occur delayed, which most often precludes specific stroke treatment in addition to multimorbidity. Such problems may also exist in other centres and highlight the need for targeted educational and organizational efforts. Simple indicators as identified in this study may help to sort out patients with true stroke more efficiently.

Isolated aphasia in the emergency department: The likelihood of ischemia is low

OBJECTIVE

Aphasia is a common presentation of ischemic stroke, often diagnosed in the acute setting using tools such as the NIH Stroke Scale (NIHSS). Due to the vascular distribution of the middle cerebral artery, it is often accompanied by other symptoms such as weakness, sensory loss, or visual changes. Isolated aphasia due to ischemia is possible, but language problems mimicking aphasia syndromes can also be seen with other diagnoses such as metabolic abnormalities or dementia. In this study, we determine the incidence of aphasia-only strokes using the NIHSS, and factors associated with a higher likelihood of ischemia.

PATIENTS AND METHODS

Over a 2year period, 788 patients presented to our Emergency Department with symptoms of acute stroke. Data were collected regarding patient demographics, medical history, presenting symptoms (based on NIHSS), work-up results, and final diagnosis. The incidence of aphasia-only stroke was calculated. Student's t-tests and chi square analysis were used to determine factors associated with ischemia.

RESULTS

Of 788 patients, 21 (3%) presented with isolated "aphasia". None of the 21 had infarcts on neuroimaging. Three (14%) were diagnosed with possible transient ischemic attacks and the rest with stroke mimics. Toxic/metabolic disturbances were the most common mimics (39%). Prior history of stroke or transient ischemic attack was associated with ischemia over mimic (p=0.023).

CONCLUSIONS

Strokes affecting language without motor or sensory deficits are uncommon. In the acute setting, isolated "aphasia" is most often due to a stroke mimic; however can occur rarely, particularly in those with prior history of ischemia.

Stroke mimics in patients with clinical signs of stroke

Background:

Stroke mimic is a major diagnostic challenge and may be difficult to distinguish from real strokes. The aim of this study was to evaluate the relative frequency of stroke mimics in patients with clinical signs of stroke.

Methods:

In this cross sectional-study, the medical records of 1985 patients with stroke admitted to Poursina Hospital were enrolled using the census technique. Data collection tool was a checklist which include age, sex, imaging results (MRI and CT scan and primary and final diagnoses.

Results:

Of the 1985 patients, 295 (14.9%) were identified with brain stroke mimics. The mean age in the group of patients with mimics and real stroke were 66.5±16.4 years and 72.4±9.6 years, respectively. The highest number of stroke belonged to 61-80 years in stroke groups (68.8%) and mimics (58.3%), respectively. There was a significant correlation between age and early diagnosis of stroke or stroke mimic (P<0.0001). The highest frequency of stroke mimics was related to brain tumors (10.5%), hypoglycemia (9.2%) and toxic poisoning (8.5%).

Conclusion:

Due to the high number of stroke mimics, further attention is necessary to aid in differential diagnosis and clinical procedures in patients with stroke signs.

In Potential Stroke Patients on Warfarin, the International Normalized Ratio Predicts Ischemia

BACKGROUND

Stroke can occur in patients on warfarin despite anticoagulation. Patients with a low international normalized ratio (INR) should theoretically be at greater risk for ischemia than those who are therapeutic. Therefore, INR may be able to indicate whether new neurological deficits are more likely strokes or stroke mimics in patients on warfarin. This study evaluates the association and predictive value of INR in determining the likelihood of ischemia.

METHODS

Patients were identified using the acute stroke registry at a Primary Stroke Center from January 2013 through December 2014. All adult patients undergoing evaluation for acute stroke with prior documented use of warfarin and an INR level at presentation were included. Data were collected regarding patient demographics, medical comorbidities, stroke severity, reason for anticoagulation, and laboratory studies including INR. Student t tests and χ2 analysis were used to evaluate factors associated with increased likelihood of ischemia (stroke or transient ischemic attack) versus mimic. Significant results were entered into a multivariable regression analysis. Sensitivity and specificity analyses were conducted to determine the predictive value of INR for ischemic risk.

RESULTS

116 patients were included; 46 were diagnosed with ischemia, 70 were diagnosed as mimics. 75% of patients were on warfarin for atrial fibrillation versus 25% for venous thrombosis. A statistically significant difference in mean INR for patients with ischemia (n = 46) versus mimics (n = 70) was observed (1.7 vs. 2.8; p < 0.001). In multivariable analysis, both sub-therapeutic INR (p < 0.001) and atrial fibrillation (p = 0.014) were predictors of ischemia. In patients with an INR ≥2, the predictive value of having a non-ischemic etiology was 79%. No patient with an INR of ≥3.6 was found to have ischemia.

CONCLUSIONS

Sub-therapeutic INR and atrial fibrillation are strongly associated with ischemia in patients on warfarin presenting with acute neurologic symptoms. Ischemia is far less likely in patients with an INR of ≥2 and rare in those with an INR ≥3.6. This study shows that the INR value of a patient on warfarin can help stratify patients' risk for acute ischemic stroke and guide further neurologic imaging and workup.

Clinical Mimics: An Emergency Medicine-Focused Review of Stroke Mimics

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.

Transient Ischemic Attack Versus Seizure: Use of Complete Blood Count Parameters for Differential Diagnosis

INTRODUCTION

Seizures are an important group of diagnoses in the differential evaluation of Transient Ischemic Attack (TIA)because of their variable and temporary signs and symptoms. Physicians must frequently rule out TIA in asymptomatic patients with normal diagnostic neuroimaging.

AIM

The current study aimed to investigate the efficacy of Complete Blood Count (CBC) components in the differential diagnosis of TIA and seizures.

MATERIALS AND METHODS

Our study was a retrospective case-control study. Patients admitted to the Emergency Department (ED) and hospitalized with an initial diagnosis of TIA or seizure at the neurology clinic of Erzurum Ataturk University Training Hospital between January 1, 2012, and December 31, 2014, were recruited for the study. Patients with inaccessible or missing data were excluded.

RESULTS

We identified 1,459 ED admissions that resulted in neurology clinic hospitalizations of patients with initial diagnoses of TIA (n=911) and seizure (n=420) over a 24-month time period. A total of 128 patients were excluded from the study.

CONCLUSION

We conclude that CBC may have a diagnostic value on TIA and seizure differentiation, but this is limited because of statistical and clinical incompatibility. Elevated White Blood Cells (WBC) values of seizure patients compared with TIA patients' may help clinicians at the preliminary phase of diagnostic studies. We conclude that age is a remarkable and valuable demographic parameter in addition to physical examination, laboratory and imaging studies.

Imaging Patterns and Management Algorithms in Acute Stroke: An Update for the Emergency Radiologist

Neuroimaging plays a key role in the initial work-up of patients with symptoms of acute stroke. Understanding the advantages and limitations of available CT and MR imaging techniques and how to use them optimally in the emergency setting is crucial for accurately making the diagnosis of acute stroke and for rapidly determining appropriate treatment.

Stroke Mimics and Acute Stroke Evaluation: Clinical Differentiation and Complications after Intravenous Tissue Plasminogen Activator

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.

MR screening of candidates for thrombolysis: How to identify stroke mimics?

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.