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Khalili N, Wang R, Garg T, Ahmed A, Hoseinyazdi M, Sair HI, Luna LP, Intrapiromkul J, Deng F, Yedavalli V. Clinical application of brain perfusion imaging in detecting stroke mimics: A review. J Neuroimaging 2023; 33:44-57. [PMID: 36207276 DOI: 10.1111/jon.13061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 02/01/2023] Open
Abstract
Stroke mimics constitute a significant proportion of patients with suspected acute ischemic stroke. These conditions may resemble acute ischemic stroke and demonstrate abnormalities on perfusion imaging sequences. The most common stroke mimics include seizure/epilepsy, migraine with aura, brain tumors, functional disorders, infectious encephalopathies, Wernicke's encephalopathy, and metabolic abnormalities. Brain perfusion imaging techniques, particularly computed tomography perfusion and magnetic resonance perfusion, are being widely used in routine clinical practice for treatment selection in patients presenting with large vessel occlusion. At the same time, the utilization of these imaging modalities enables the opportunity to better diagnose patients with stroke mimics in a time-sensitive setting, leading to appropriate management, decision-making, and resource allocation. In this review, we describe patterns of perfusion abnormalities that could discriminate patients with stroke mimics from those with acute ischemic stroke and provide specific case examples to illustrate these perfusion abnormalities. In addition, we discuss the challenges associated with interpretation of perfusion images in stroke-related pathologies. In general, perfusion imaging can provide additional information in some cases-when used in combination with conventional magnetic resonance imaging and computed tomography-and might help in detecting stroke mimics among patients who present with acute onset focal neurological symptoms.
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Affiliation(s)
- Neda Khalili
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Richard Wang
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Tushar Garg
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Amara Ahmed
- Department of Radiology, Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Meisam Hoseinyazdi
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Haris I Sair
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Licia P Luna
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jarunee Intrapiromkul
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Francis Deng
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Romoli M, Merli E, Galluzzo S, Muccioli L, Testoni S, Zaniboni A, Contardi S, Simonetti L, Tinuper P, Zini A. Hyperperfusion Tmax mapping for nonconvulsive status epilepticus in the acute setting: A pilot case-control study. Epilepsia 2022; 63:2534-2542. [PMID: 35793391 PMCID: PMC9796764 DOI: 10.1111/epi.17359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/02/2022] [Accepted: 07/05/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Nonconvulsive status epilepticus (NCSE) is misdiagnosed in >50% of cases in the emergency department. Computed tomographic perfusion (CTP) has been implemented in the hyperacute setting to detect seizure-induced hyperperfusion. However, the diagnostic value of CTP is limited by the lack of thresholds for hyperperfusion and high interrater variability. This pilot case-control study aims at identifying the diagnostic value of reverse Tmax (rTmax) in differentiating NCSE from acute ischemic stroke in the hyperacute setting. METHODS We enrolled patients with NCSE (Salzburg criteria-based diagnosis) and stroke cases 1:1 matched for clinical features and time of presentation. CTP standard maps (mean transit time [MTT]-cerebral blood volume-cerebral blood flow [CBF]) and rTmax maps were elaborated and rated by two experts in CTP blinded to the final diagnosis. Hyperperfusion was adjudicated for standard CTP maps as an increase in CBF and a decrease in MTT, and for rTmax as the presence of a black area on 3-, 2-, and 1-s threshold maps. Cronbach alpha was used for interrater agreement; receiver operating curve analysis was run to measure accuracy with area under the curve. RESULTS Overall, 34 patients were included (17 NCSE, 17 stroke; time from onset to imaging = 2 h for both groups). People with NCSE were older and more frequently had a history of epilepsy. NCSE patients had hyperperfusion on rTmax maps in 11 of 17 cases versus zero of 17 in stroke. Intra- and interrater reliability was higher for rTmax than for standard CTP maps (κ = 1 vs. κ = .6). rTmax was 82% (95%CI = 67-97%) accurate in predicting NCSE versus stroke in the hyperacute setting. Agreement between neuroimaging and electroencephalography (EEG) was limited at a hemispheric level for standard CTP maps, whereas rTMax had agreement with EEG largely reaching the sublobar level. SIGNIFICANCE rTmax mapping might represent a reliable tool to spot NCSE-induced hyperperfusion with a threshold-based reproducible approach. Further studies are needed for validation and implementation in the differential diagnosis of focal neurological deficit in the hyperacute setting.
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Affiliation(s)
| | - Elena Merli
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Simone Galluzzo
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeuroradiologia, Ospedale MaggioreBolognaItaly
| | - Lorenzo Muccioli
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBolognaItaly
| | - Stefania Testoni
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Anna Zaniboni
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Sara Contardi
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
| | - Luigi Simonetti
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeuroradiologia, Ospedale MaggioreBolognaItaly
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBolognaItaly,IRCCS Istituto delle ScienzeNeurologiche di BolognaFull Member of the ERN EpiCAREBolognaItaly
| | - Andrea Zini
- IRCCS Istituto delle ScienzeNeurologiche di BolognaNeurologia e Rete Stroke Metropolitana, OspedaleMaggioreBolognaItaly
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Gonzalez-Martinez A, Trillo S, Benavides-Bernaldo de Quirós C, Casado-Fernández L, De Toledo M, Barbosa-Del Olmo A, Vega Piris L, Ramos C, Manzanares-Soler R, Ximénez-Carrillo Á, Vivancos J. Predictors of perfusion computed tomography alterations in stroke mimics attended as stroke code. Eur J Neurol 2021; 28:1939-1948. [PMID: 33609295 DOI: 10.1111/ene.14783] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Stroke mimics (SMs) account for a significant number of patients attended as stroke code (SC) with an increasing number over the years. Recent studies show perfusion computed tomography (PCT) alterations in some SMs, especially in seizures. The objective of our study was to evaluate the clinical characteristics and PCT alterations in SMs attended as SC in order to identify potential predictors of PCT alterations in SMs. METHODS A retrospective study was performed including all SC activations undergoing a multimodal CT study including non-enhanced computed tomography (CT), CT angiography and PCT, as part of our SC protocol, over 39 months. Patients with a final diagnosis of SM after complete diagnosis work-up were therefore selected. Clinical variables, diagnosis, PCT alteration patterns and type of map affected (Tmax or time to peak, cerebral blood flow and cerebral blood volume) were registered. RESULTS Stroke mimics represent up to 16% (284/1761) of SCs with a complete multimodal study according to our series. Amongst SMs, 26% (74/284) showed PCT alterations. PCT abnormalities are more prevalent in seizures and status epilepticus and the main pattern is alteration of the time to peak map, of unilateral hemispheric distribution or of non-vascular territory. In our series, the independent predictors of alteration in PCT in SMs are aphasia, female sex and older age. CONCLUSIONS Perfusion computed tomography alterations can be found amongst almost a third of SMs attended as SC, especially older women presenting with aphasia with a final diagnosis of epileptic seizures and status epilepticus.
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Affiliation(s)
- Alicia Gonzalez-Martinez
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - Santiago Trillo
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | | | - Laura Casado-Fernández
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - María De Toledo
- Epilepsy Unit, Department of Neurology, Hospital Universitario de la Princesa, Madrid, Spain
| | - Antonio Barbosa-Del Olmo
- Neuroradiology Unit, Department of Radiology, Hospital Universitario de la Princesa, Madrid, Spain
| | - Lorena Vega Piris
- Methodological Support Unit, Hospital Universitario de La Princesa, Madrid, Spain
| | - Carmen Ramos
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - Rafael Manzanares-Soler
- Neuroradiology Unit, Department of Radiology, Hospital Universitario de la Princesa, Madrid, Spain
| | - Álvaro Ximénez-Carrillo
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - José Vivancos
- Stroke Unit, Department of Neurology and, Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
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Lucas L, Gariel F, Menegon P, Aupy J, Thomas B, Tourdias T, Sibon I, Renou P. Acute Ischemic Stroke or Epileptic Seizure? Yield of CT Perfusion in a "Code Stroke" Situation. AJNR Am J Neuroradiol 2021; 42:49-56. [PMID: 33431502 DOI: 10.3174/ajnr.a6925] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/27/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The clinical differentiation between acute ischemic stroke and epileptic seizure may be challenging, and making the correct diagnosis could avoid unnecessary reperfusion therapy. We examined the accuracy of CTP in discriminating epileptic seizures from acute ischemic stroke without identified arterial occlusion. MATERIALS AND METHODS We retrospectively identified consecutive patients in our emergency department who underwent CTP in the 4.5 hours following the development of an acute focal neurologic deficit who were discharged with a final diagnosis of acute ischemic stroke or epileptic seizure. RESULTS Among 95 patients, the final diagnosis was epileptic seizure in 45 and acute ischemic stroke in 50. CTP findings were abnormal in 73% of the patients with epileptic seizure and 40% of those with acute ischemic stroke. Hyperperfusion was observed more frequently in the seizure group (36% versus 2% for acute ischemic stroke) with high specificity (98%) but low sensitivity (35%) for the diagnosis of epileptic seizure. Hypoperfusion was found in 38% of cases in each group and was not confined to a vascular territory in 24% of patients in the seizure group and 2% in the acute ischemic stroke group. The interobserver agreement was good (κ = 0.60) for hypo-, hyper-, and normoperfusion patterns and moderate (κ = 0.41) for the evaluation of vascular systematization. CONCLUSIONS CTP patterns helped to differentiate acute ischemic stroke from epileptic seizure in a "code stroke" situation. Our results indicate that a hyperperfusion pattern, especially if not restricted to a vascular territory, may suggest reconsideration of intravenous thrombolysis therapy.
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Affiliation(s)
- L Lucas
- From the Department of Neurology (L.L., I.S., P.R.), Stroke Unit .,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - F Gariel
- Departments of Neuroradiology (F.G., B.T., T.T.)
| | | | - J Aupy
- Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France.,Institut des Matériaux Jean Rouxel, (J.A.), Union Mutualiste Retraite, Centre national de la recherche scientifique, University of Bordeaux, Bordeaux, France
| | - B Thomas
- Departments of Neuroradiology (F.G., B.T., T.T.).,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - T Tourdias
- Departments of Neuroradiology (F.G., B.T., T.T.).,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - I Sibon
- From the Department of Neurology (L.L., I.S., P.R.), Stroke Unit.,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - P Renou
- From the Department of Neurology (L.L., I.S., P.R.), Stroke Unit
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Khoo CS, Kim SE, Lee BI, Shin KJ, Ha SY, Park J, Park KM, Bae SY, Lee D, Kim BJ, Bae MJ, Kim SE. Characteristics of Perfusion Computed Tomography Imaging in Patients with Seizures Mimicking Acute Stroke. Eur Neurol 2020; 83:56-64. [DOI: 10.1159/000506591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/15/2020] [Indexed: 11/19/2022]
Abstract
Introduction: Seizures as acute stroke mimics are a diagnostic challenge. Objective: The aim of the study was to characterize the perfusion patterns on perfusion computed tomography (PCT) in patients with seizures masquerading as acute stroke. Methods: We conducted a study on patients with acute seizures as stroke mimics. The inclusion criteria for this study were patients (1) initially presenting with stroke-like symptoms but finally diagnosed to have seizures and (2) with PCT performed within 72 h of seizures. The PCT of seizure patients (n = 27) was compared with that of revascularized stroke patients (n = 20) as the control group. Results: Among the 27 patients with seizures as stroke mimics, 70.4% (n = 19) showed characteristic PCT findings compared with the revascularized stroke patients, which were as follows: (1) multi-territorial cortical hyperperfusion {(73.7% [14/19] vs. 0% [0/20], p = 0.002), sensitivity of 73.7%, negative predictive value (NPV) of 80%}, (2) involvement of the ipsilateral thalamus {(57.9% [11/19] vs. 0% [0/20], p = 0.007), sensitivity of 57.9%, NPV of 71.4%}, and (3) reduced perfusion time {(84.2% [16/19] vs. 0% [0/20], p = 0.001), sensitivity of 84.2%, NPV of 87%}. These 3 findings had 100% specificity and positive predictive value in predicting patients with acute seizures in comparison with reperfused stroke patients. Older age was strongly associated with abnormal perfusion changes (p = 0.038), with a mean age of 66.8 ± 14.5 years versus 49.2 ± 27.4 years (in seizure patients with normal perfusion scan). Conclusions: PCT is a reliable tool to differentiate acute seizures from acute stroke in the emergency setting.
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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".
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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
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Abstract
INTRODUCTION Stroke is a significant underlying cause of epilepsy. Seizures due to ischemic stroke (IS) are generally categorized into early seizures (ESs) and late seizures (LSs). Seizures in thrombolysis situations may raise the possibility of other etiology than IS. AIM We overtook a systematic review focusing on the pathogenesis, prevalence, risk factors, detection, management, and clinical outcome of ESs in IS and in stroke/thrombolysis situations. We also collected articles focusing on the association of recombinant tissue-type plasminogen activator (rt-PA) treatment and epileptic seizures. RESULTS We have identified 37 studies with 36,775 participants. ES rate was 3.8% overall in patients with IS with geographical differences. Cortical involvement, severe stroke, hemorrhagic transformation, age (<65 years), large lesion, and atrial fibrillation were the most important risk factors. Sixty-one percent of ESs were partial and 39% were general. Status epilepticus (SE) occurred in 16.3%. 73.6% had an onset within 24 h and 40% may present at the onset of stroke syndrome. Based on EEG findings seizure-like activity could be detected only in approximately 18% of ES patients. MRI diffusion-weighted imaging and multimodal brain imaging may help in the differentiation of ischemia vs. seizure. There are no specific recommendations with regard to the treatment of ES. CONCLUSION ESs are rare complications of acute stroke with substantial burden. A significant proportion can be presented at the onset of stroke requiring an extensive diagnostic workup.
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The role of CT perfusion in the evaluation of seizures, the post-ictal state, and status epilepticus. Epilepsy Res 2020; 159:106256. [DOI: 10.1016/j.eplepsyres.2019.106256] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 11/17/2019] [Accepted: 12/09/2019] [Indexed: 01/11/2023]
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9
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Polymeris AA, Curtze S, Erdur H, Hametner C, Heldner MR, Groot AE, Zini A, Béjot Y, Dietrich A, Martinez-Majander N, von Rennenberg R, Gumbinger C, Schaedelin S, De Marchis GM, Thilemann S, Traenka C, Lyrer PA, Bonati LH, Wegener S, Ringleb PA, Tatlisumak T, Nolte CH, Scheitz JF, Arnold M, Strbian D, Nederkoorn PJ, Gensicke H, Engelter ST. Intravenous thrombolysis for suspected ischemic stroke with seizure at onset. Ann Neurol 2019; 86:770-779. [PMID: 31435960 DOI: 10.1002/ana.25582] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/06/2019] [Accepted: 08/18/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Seizure at onset (SaO) has been considered a relative contraindication for intravenous thrombolysis (IVT) in patients with acute ischemic stroke, although this appraisal is not evidence based. Here, we investigated the prognostic significance of SaO in patients treated with IVT for suspected ischemic stroke. METHODS In this multicenter, IVT-registry-based study we assessed the association between SaO and symptomatic intracranial hemorrhage (sICH, European Cooperative Acute Stroke Study II definition), 3-month mortality, and 3-month functional outcome on the modified Rankin Scale (mRS) using unadjusted and adjusted logistic regression, coarsened exact matching, and inverse probability weighted analyses. RESULTS Among 10,074 IVT-treated patients, 146 (1.5%) had SaO. SaO patients had significantly higher National Institutes of Health Stroke Scale score and glucose on admission, and more often female sex, prior stroke, and prior functional dependence than non-SaO patients. In unadjusted analysis, they had generally less favorable outcomes. After controlling for confounders in adjusted, matched, and weighted analyses, all associations between SaO and any of the outcomes disappeared, including sICH (odds ratio [OR]unadjusted = 1.53 [95% confidence interval (CI) = 0.74-3.14], ORadjusted = 0.52 [95% CI = 0.13-2.16], ORmatched = 0.68 [95% CI = 0.15-3.03], ORweighted = 0.95 [95% CI = 0.39-2.32]), mortality (ORunadjusted = 1.49 [95% CI = 1.00-2.24], ORadjusted = 0.98 [95% CI = 0.5-1.92], ORmatched = 1.13 [95% CI = 0.55-2.33], ORweighted = 1.17 [95% CI = 0.73-1.88]), and functional outcome (mRS ≥ 3/ordinal mRS: ORunadjusted = 1.33 [95% CI = 0.96-1.84]/1.35 [95% CI = 1.01-1.81], ORadjusted = 0.78 [95% CI = 0.45-1.32]/0.78 [95% CI = 0.52-1.16], ORmatched = 0.75 [95% CI = 0.43-1.32]/0.45 [95% CI = 0.10-2.06], ORweighted = 0.87 [95% CI = 0.57-1.34]/1.00 [95% CI = 0.66-1.52]). These results were consistent regardless of whether patients had an eventual diagnosis of ischemic stroke (89/146) or stroke mimic (57/146 SaO patients). INTERPRETATION SaO was not an independent predictor of poor prognosis. Withholding IVT from patients with assumed ischemic stroke presenting with SaO seems unjustified. ANN NEUROL 2019;86:770-779.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sami Curtze
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hebun Erdur
- Department of Neurology, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Adrien E Groot
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Andrea Zini
- IRCCS Istituto di Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Yannick Béjot
- University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France
| | - Annina Dietrich
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | | | | | - Christoph Gumbinger
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sebastian Thilemann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Turgut Tatlisumak
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Neurology, Sahlgrenska University Hospital and Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Christian H Nolte
- Department of Neurology, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
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González‐Cuevas M, Coscojuela P, Santamarina E, Pareto D, Quintana M, Sueiras M, Guzman L, Sarria S, Salas‐Puig X, Toledo M, Rovira À. Usefulness of brain perfusion CT in focal‐onset status epilepticus. Epilepsia 2019; 60:1317-1324. [DOI: 10.1111/epi.16063] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Montserrat González‐Cuevas
- Epilepsy Unit Neurology Department Hospital Universitari Vall d'Hebron Barcelona Spain
- Department of Medicine Universitat Autonoma de Barcelona Barcelona Spain
| | - Pilar Coscojuela
- Neuroradiology Section Radiology Department Hospital Universitari Vall d'Hebron Barcelona Spain
| | - Estevo Santamarina
- Epilepsy Unit Neurology Department Hospital Universitari Vall d'Hebron Barcelona Spain
- Department of Medicine Universitat Autonoma de Barcelona Barcelona Spain
| | - Deborah Pareto
- Neuroradiology Section Radiology Department Hospital Universitari Vall d'Hebron Barcelona Spain
| | - Manuel Quintana
- Epilepsy Unit Neurology Department Hospital Universitari Vall d'Hebron Barcelona Spain
- Department of Medicine Universitat Autonoma de Barcelona Barcelona Spain
| | - María Sueiras
- Neurophysiology Unit Hospital Universitari Vall d'Hebron Barcelona Spain
| | - Lorena Guzman
- Neurophysiology Unit Hospital Universitari Vall d'Hebron Barcelona Spain
| | - Silvana Sarria
- Neuroradiology Section Radiology Department Hospital Universitari Vall d'Hebron Barcelona Spain
| | - Xavier Salas‐Puig
- Epilepsy Unit Neurology Department Hospital Universitari Vall d'Hebron Barcelona Spain
- Department of Medicine Universitat Autonoma de Barcelona Barcelona Spain
| | - Manuel Toledo
- Epilepsy Unit Neurology Department Hospital Universitari Vall d'Hebron Barcelona Spain
- Department of Medicine Universitat Autonoma de Barcelona Barcelona Spain
| | - Àlex Rovira
- Neuroradiology Section Radiology Department Hospital Universitari Vall d'Hebron Barcelona Spain
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Abstract
The most feared complication after acute ischemic stroke is symptomatic or asymptomatic hemorrhagic conversion. Neuroimaging and clinical criteria are used to predict development of hemorrhage. Seizures after acute ischemic stroke or stroke-like symptoms from seizures are not common but may lead to confusion in the peristroke period, especially if seizures are repetitive or evolve into status epilepticus, which could affect neuroimaging findings. Malignant infarction develops when cytotoxic edema is large enough to lead to herniation and death. Post-stroke neuroimaging prognosticators have been described and should be assessed early so that appropriate treatment is offered before herniation leads to additional tissue injury.
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Austein F, Huhndorf M, Meyne J, Laufs H, Jansen O, Lindner T. Advanced CT for diagnosis of seizure-related stroke mimics. Eur Radiol 2017; 28:1791-1800. [DOI: 10.1007/s00330-017-5174-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/25/2017] [Accepted: 11/06/2017] [Indexed: 12/19/2022]
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