Atypical presentations of acute cerebrovascular syndromes

Moving From CT to MRI Paradigm in Acute Ischemic Stroke: Feasibility, Effects on Stroke Diagnosis and Long-Term Outcomes

BACKGROUND

The relative value of computed tomography (CT) and magnetic resonance imaging (MRI) in acute ischemic stroke (AIS) is debated. In May 2018, our center transitioned from using CT to MRI as first-line imaging for AIS. This retrospective study aims to assess the effects of this paradigm change on diagnosis and disability outcomes.

METHODS

We compared all consecutive patients with confirmed diagnosis of AIS admitted to our center during the MRI-period (May 2018-August 2022) and an identical number of patients from the preceding CT-period (December 2012-April 2018). Univariable and multivariable analyses were performed to evaluate outcomes, including the number and delay of imaging exams, the rate of missed strokes, stroke mimics treated with thrombolysis, undetermined stroke mechanisms, length of hospitalization, and 3-month disability.

RESULTS

The median age of the 2972 included patients was 76 years (interquartile range, 65-84), and 46% were female. In the MRI-period, 80% underwent MRI as first acute imaging. The proportion of patients requiring a second acute imaging modality for diagnostic ± revascularization reasons increased from 2.1% to 5% (Punadj <0.05), but it decreased in the subacute phase from 79.0% to 60.1% (Padj <0.05). In thrombolysis candidates, there was a 2-minute increase in door-to-imaging delay (Padj <0.05). The rates of initially missed AIS diagnosis was similar (3.8% versus 4.4%, Padj=0.32) and thrombolysis in stroke mimics decreased by half (8.6% versus 4.3%; Padj <0.05). Rates of unidentified stroke mechanism at hospital discharge were similar (22.8% versus 28.1%; Padj=0.99). The length of hospitalization decreased from 9 (interquartile range, 6-14) to 7 (interquartile range, 4-12) days (Padj=0.62). Disability at 3 months was similar (common adjusted odds ratio for favorable Rankin shift, 0.98 [95% CI, 0.71-1.36]; Padj=0.91), as well as mortality and symptomatic intracranial hemorrhage.

CONCLUSIONS

A paradigm shift from CT to MRI as first-line imaging for AIS seems feasible in a comprehensive stroke center, with a minimally increased delay to imaging in thrombolysis candidates. MRI was associated with reduced thrombolysis rates of stroke mimics and subacute neuroimaging needs.

Quality control in treating patients with patent foramen ovale: 7-year-experience of the Heart and Brain team of the Careggi University Hospital

BACKGROUND

The right comprehension of ischemic stroke pathogenesis guarantees the best prevention therapy. The term "patent foramen ovale (PFO) related stroke" has been proposed for those events where PFO is supposed to be pathogenetic, but their definition is challenging. A multidisciplinary evaluation in a "Heart & Brain" team (HBteam) including stroke neurologists and interventional cardiologists was therefore highly recommended in the recent guidelines of secondary stroke prevention.

OBJECTIVE

We aimed at describing the organization of the HBteam of Careggi-University-Hospital of Florence (Italy), and the results of the first seven years of activity.

METHODS

In 2016 Interventional Cardiologists and Stroke Neurologists set up an outpatient clinic for the joined evaluation of patients with PFO and other cardio/neurological conditions. A specific diagnostic-therapeutic hospital plan was produced for PFO patients. Patient empowerment was guaranteed by a hospital explicative webpage, a booklet regarding risks/benefits of PFO closure and a 3D heartmodel to simulate the intervention. Data were collected in a dedicated registry.

RESULTS

We evaluated 594 patients for PFO, 40 for left atrial appendage closure and 38 for other conditions. In 20% of PFO-patients, HBteam diagnosis was discordant from that of referring physicians, 14% were stroke misdiagnoses. We advised against closure in 53% of patients. At follow-up 94% of closed patients had no/minimum residual shunt; 3 patients had a cerebral ischemic event.

CONCLUSIONS

A dedicated HBteam represents a unique opportunity to share decisions with patients after a thorough empowerment process. The joining of cardioneurological skills allows a better classification of PFO-patients, reducing futile interventions.

Stroke in Young Adults

Stroke in young adults is associated with significant morbidity, and its prevalence is rising in the United States. This is partly attributed to a rise in the prevalence of traditional risk factors including hypertension, hypercholesterolemia, obesity, diabetes mellitus, smoking and heart disease. In addition, there are non-modifiable risk factors comprising migraine, pregnancy and postpartum state, illicit drug use, oral contraceptives and hypercoagulable state. The mechanisms causing stroke in young adults are unique and include cervical dissection, cardioembolic phenomenon, vasculitis and vasculopathy, connective tissue disease, patent foramen ovale and cerebral venous thrombosis. The diagnosis of stroke in the young population can be challenging given its myriad clinical presentations. In this document, we provide an overview of the epidemiology of stroke in young adults, explore mechanisms that may explain increasing rates of stroke in this population, and provide a critical updated overview of the existing literature on the management and prevention of stroke in young adults.

Thrombectomy versus Medical Management for Isolated Anterior Cerebral Artery Stroke: An International Multicenter Registry Study

Background Evidence supporting a potential benefit of thrombectomy for distal medium vessel occlusions (DMVOs) of the anterior cerebral artery (ACA) is, to the knowledge of the authors, unknown. Purpose To compare the clinical and safety outcomes between mechanical thrombectomy (MT) and best medical treatment (BMT) with or without intravenous thrombolysis for primary isolated ACA DMVOs. Materials and Methods Treatment for Primary Medium Vessel Occlusion Stroke, or TOPMOST, is an international, retrospective, multicenter, observational registry of patients treated for DMVO in daily practice. Patients treated with thrombectomy or BMT alone for primary ACA DMVO distal to the A1 segment between January 2013 and October 2021 were analyzed and compared by one-to-one propensity score matching (PSM). Early outcome was measured by the median improvement of National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours. Favorable functional outcome was defined as modified Rankin scale scores of 0-2 at 90 days. Safety was assessed by the occurrence of symptomatic intracerebral hemorrhage and mortality. Results Of 154 patients (median age, 77 years; quartile 1 [Q1] to quartile 3 [Q3], 66-84 years; 80 men; 94 patients with MT; 60 patients with BMT) who met the inclusion criteria, 110 patients (median age, 76 years; Q1-Q3, 67-83 years; 50 men; 55 patients with MT; 55 patients with BMT) were matched. DMVOs were in A2 (82 patients; 53%), A3 (69 patients; 45%), and A3 (three patients; 2%). After PSM, the median 24-hour NIHSS point decrease was -2 (Q1-Q3, -4 to 0) in the thrombectomy and -1 (Q1-Q3, -4 to 1.25) in the BMT cohort (P = .52). Favorable functional outcome (MT vs BMT, 18 of 37 [49%] vs 19 of 39 [49%], respectively; P = .99) and mortality (MT vs BMT, eight of 37 [22%] vs 12 of 39 [31%], respectively; P = .36) were similar in both groups. Symptomatic intracranial hemorrhage occurred in three (2%) of 154 patients. Conclusion Thrombectomy appears to be a safe and technically feasible treatment option for primary isolated anterior cerebral artery occlusions in the A2 and A3 segment with clinical outcomes similar to best medical treatment with and without intravenous thrombolysis. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Zhu and Wang in this issue.

Atypical painful stroke presentations: A review

Stroke is a leading cause of death and disability. Some patients may present with atypical symptoms. One of the very rare presentations of stroke is initial neurogenic pain. Rare painful presentations include, amongst others, acute trigeminal neuralgia, atypical facial pain, hemi-sensory pain, and episodic pain. Based on the available literature, the pain at presentation may be episodic, transient, or persistent, and it may herald other debilitating stroke symptoms such as hemiparesis. Pain quality is often described as burning; less often as sharp. Patients often have accompanying focal symptoms and findings on neurological examination. However, in several of the reviewed cases, these were discrete or non-existent. In patients with pain located in the trunk and/or extremities, lesions may involve the thalamus, lateral medulla oblongata, insula, or parietal lobe. In patients with atypical facial or orbital pain (including the burning "salt and pepper" sensation), the stroke lesions are typically located in the pons. In this narrative review, we included studies/case series of patients who had pain at the time of onset, shortly before or within 24 h of stroke symptoms (on the day of admission). Cases with pain related to aortic or cervical vessel dissection, cerebral venous sinus thrombosis, subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome, and CNS vasculitis were excluded. With this review, we aim to summarize the current knowledge on stroke presenting with acute pain.

Barriers to and facilitators for making emergency calls - a qualitative interview study of stroke patients and witnesses

BACKGROUND AND OBJECTIVES

Early access to hospital for diagnosis and treatment is strongly recommended for patients with acute stroke. Unfortunately, prehospital delay frequently occurs. The aim of the current study was to gain in-depth insight into patient experience and behavior in the prehospital phase of a stroke.

METHODS

We conducted qualitative interviews with a purposive sample of 11 patients and six witnesses within four weeks post stroke. The interviews were audio recorded, transcribed, and analyzed utilizing Systematic Text Condensation.

RESULTS

The material was classified according to two main categories each containing three subgroups. The first category contained the diversity of sudden changes that all participants noticed. The subgroups were confusing functional changes, distinct bodily changes and witnesses' observations of abnormal behavior or signs. The second category was delaying and facilitating factors. To trivialize or deny stroke symptoms, or having a high threshold for contacting emergency services, led to time delay. Factors facilitating early contact were severe stroke symptoms, awareness of the consequences of stroke or a witness standing by when the stroke occurred.

CONCLUSIONS

Prehospital delays involved interrelated elements: (1) Difficulties in recognition of a stroke when symptoms were mild, odd and/or puzzling; (2) Recognition of a stroke or need for medical assistance were facilitated by interaction/communication; (3) High threshold for calling emergency medical services, except when symptoms were severe. The findings may be helpful in planning future public stroke campaigns and in education and training programs for health personnel.

Acute delirium as an initial manifestation of COVID-19 patients with acute ischemic stroke: Report on two cases

Psychiatric and neurological complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are common. Psychiatric symptoms are so common that they are easily misinterpreted as an affective disorder induced by SARSCoV-2 infection. However, psychiatric symptoms, such as acute delirium, though rarely seen, can be the initial manifestations of acute ischemic stroke (AIS). These psychiatric symptoms may confuse the diagnosis of acute stroke, which needs correct and timely management. We report two hospitalized cases with SARS-CoV-2 infection and elevated serum D-dimer levels having acute delirium as the initial manifestation of AIS. The diagnostic processes were challenging and time-consuming, so reperfusion therapy could not be given in the therapeutic time window. The diagnoses of AIS were finally made by brain magnetic resonance imaging which showed diffusion restriction at the right middle cerebral artery territory in both cases. Features of psychiatric complications and stroke in coronavirus disease 2019 (COVID-19) patients are reviewed. For the hospitalized COVID-19 patients with elevated levels of serum Ddimer and acute delirium, acute stroke with neuropsychiatric manifestations should beconsidered.

Ischemic stroke mimics: A comprehensive review

BACKGROUND

Ischemic stroke is the leading cause of disability and one of the leading causes of death. Ischemic stroke mimics (SMs) can account for a noteble number of diagnosed acute strokes and even can be thrombolyzed.

METHODS

The aim of our comprehensive review was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of SMs in stroke/thrombolysis situations.

RESULTS

Overall, 61 studies were selected with 62.664 participants. Ischemic stroke mimic rate was 24.8% (15044/60703). Most common types included peripheral vestibular dysfunction in 23.2%, toxic/metabolic in 13.2%, seizure in 13%, functional disorder in 9.7% and migraine in 7.76%. Ischemic stroke mimic have less vascular risk factors, younger age, female predominance, lower (nearly normal) blood pressure, no or less severe symptoms compared to ischemic stroke patients (p < 0.05 in all cases). 61.7% of ischemic stroke patients were thrombolysed vs. 26.3% among SMs (p < 0.001). (p < 0.001). Overall intracranial hemorrhage was reported in 9.4% of stroke vs. 0.7% in SM patients (p < 0.001). Death occurred in 11.3% of stroke vs 1.9% of SM patients (p < 0.001). Excellent outcome was (mRS 0-1) was reported in 41.8% ischemic stroke patients vs. 68.9% SMs (p < 0.001). Apart from HINTS manouvre or Hoover sign there is no specific method in the identification of mimics. MRI DWI or perfusion imaging have a role in the setup of differential diagnosis, but merit further investigation.

CONCLUSION

Our article is among the first complex reviews focusing on ischemic stroke mimics. Although it underscores the safety of thrombolysis in this situation, but also draws attention to the need of patient evaluation by physicians experienced in the diagnosis of both ischemic stroke and SMs, especially in vertigo, headache, seizure and conversional disorders.

Endovascular treatment of anterior cerebral artery occlusions

There are limited data on endovascular treatment (EVT) for anterior cerebral artery (ACA) occlusions. This review focuses on aspects related to ACA EVT: ACA anatomy, clinical and imaging findings, prognosis of ACA stroke, and ACA thrombectomy techniques. The ACA anatomy, and the regions supplied by the ACA, are highly variable; frequent anatomical variants include azygos ACA, triplicated ACA and fenestrations of the anterior communicating artery. ACA occlusions can be classified based on occlusion location, their continuity with other vessel occlusions (isolated ACA occlusion vs ACA occlusion as part of a carotid T occlusion) and etiology (primary-spontaneous ACA occlusion, vs secondary-spontaneous or iatrogenic due to clot fragmentation/migration). Symptoms of ACA stroke differ in severity and nature due to large inter-individual variations in territorial ACA blood supply. Generally, ACA strokes are severely disabling, and the typical clinical hallmark is a motor deficit of the contralateral lower extremity. Advanced imaging (CT perfusion, multiphase CT angiography) increases the likelihood of the correct diagnosis of ACA stroke and should be obtained on routine basis.Available data for ACA EVT suggest its feasibility and safety while clinical outcomes are often unfavorable with conservative management. Therefore, the potential benefit of EVT seems obvious. An optimized endovascular approach for ACA thrombectomy comprises the development and use of smaller and softer devices that can be delivered through small microcatheters with an optimized vector of force. Ultimately, generating high-level evidence for ACA EVT from randomized trials remains warranted.

Bilateral Thalamic Stroke as a Cause of Decreased Responsiveness

We report the case of a 77-year-old male with no prior history of stroke who came in as a stroke alert for right facial droop and speech slurring, but upon presentation he had decreased responsiveness. Initial imaging for stroke was negative. Laboratory evaluation revealed no abnormalities. As lumbar puncture was about to be performed, the patient had a sudden resolution of symptoms, became responsive, and started answering questions. Magnetic resonance imaging (MRI) revealed small acute infarcts in the bilateral thalami and adjacent central aspect of the midbrain, right larger than the left. General decreased responsiveness needs to be considered in the differential diagnosis of stroke.

Neurological manifestations in patients with symptomatic COVID-19 admitted to the Bafoussam Regional Hospital, Cameroon

INTRODUCTION

although the main manifestations of COVID-19 are respiratory, several neurological symptoms and complications have also been reported. The pandemic seems to have some epidemiological specificities in sub-Saharan Africa, and this may be reflected in the type and frequency of neurological symptoms. This study aimed to report neurological manifestations associated with symptomatic COVID-19 in a sub-Saharan African setting.

METHODS

we conducted a retrospective review of symptomatic PCR-confirmed COVID-19 cases admitted to the Bafoussam Regional Hospital between March and September 2020. Patients' files were reviewed at discharge by a consultant neurologist. Socio-demographic characteristics, co-morbidities, symptoms on admission, neurological symptoms during hospitalization, management, and in-hospital outcome were recorded. Comparisons between patients with and without neurological symptoms were performed using Fisher's exact and Mann-Whitney U test.

RESULTS

we enrolled 177 symptomatic patients (68% men). Mean age was 54.6 ± 17.8 years (range 2-99 years). Co-morbidities were present in 57.6% of patients, including hypertension (27.1%) and diabetes mellitus (25.4%). Neurological symptoms were found in 113 (63.8%) patients. The most frequent were headache (39.0%), myalgia (35.6%), anosmia (11.9%), impaired consciousness (10.7%) and delirium (5.6%). Regarding the presenting symptoms, fever was more frequent in patients with neurological symptoms than in those without (81.4% versus 50.0%, p< 0.001), while digestive symptoms were less frequent in patients with neurological symptoms (0.9% versus 9.4%, p= 0.004).

CONCLUSION

neurological manifestations are frequent and heterogeneous in patients with symptomatic COVID-19. Further studies are needed to clarify the pathophysiology of neurological symptoms in COVID-19 and their impact on patients' long-term outcome.

High-Risk Chief Complaints III: Neurologic Emergencies

A careful history and thorough physical examination are necessary in patients presenting with acute neurologic dysfunction. Patients presenting with headache should be screened for red-flag criteria that suggest a dangerous secondary cause warranting imaging and further diagnostic workup. Dizziness is a vague complaint; focusing on timing, triggers, and examination findings can help reduce diagnostic error. Most patients presenting with back pain do not require emergent imaging, but those with new neurologic deficits or signs/symptoms concerning for acute infection or cord compression warrant MRI. Delay to diagnosis and treatment of acute ischemic stroke is a frequent reason for medical malpractice claims.

A Primer on Computed Tomography Perfusion Imaging for the Emergency Physician

BACKGROUND

Brain noncontrast computed tomography (CT), CT angiography, and magnetic resonance imaging have been used clinically for decades, and emergency physicians have a good understanding of their indications, the meaning of their results, and some facility with the interpretation of CT. However, brain CT perfusion (CTP) is relatively new and emergency physicians are less familiar with its basic concepts, indications, and role in managing patients with neurological emergencies.

OBJECTIVE

We will review the parameters of clinical interest on a CTP report, and how to incorporate them into clinical decision-making.

DISCUSSION

Endovascular therapies paired with CTP have opened up a new frontier in stroke management for severely debilitated stroke patients. It is important for emergency physicians to have an understanding of CTP and how to use it clinically.

CONCLUSION

Taking care of patients with large-vessel occlusions is multidisciplinary, and emergency physicians need to understand CTP imaging and its clinical utility.

Depression As a Consequence of Frontal Lobe Infarction: A Case Report

Stroke is one of the most important and prevalent causes of morbidity and mortality around the world, with the most common site of vascular lesions being the frontal lobe. Usually, strokes present with motor or speech abnormalities. Depression or other psychiatric disturbances being the sole presenting feature of a stroke is a rare occurrence. Sudden onset of behavioral disturbances should alert the physician to investigate the patient for an underlying cause of his/her disorder. We present the case of a 65-year-old diabetic male who presented with sudden low mood and apathy that caused him severe socio-economic losses. He was initially diagnosed with depressive disorder but failed to respond to treatment. He was investigated, and a computed tomography (CT) scan of the brain led to the correct diagnosis, an old left frontal infarct. In patients with behavioral disorders, which are sudden in onset or not responding to treatment, secondary causes should always be considered.

Avoiding Misdiagnosis in Patients With Posterior Circulation Ischemia: A Narrative Review

Posterior circulation strokes represent 20% of all acute ischemic strokes. Posterior circulation stroke patients are misdiagnosed twice as often compared to those with anterior events. Misdiagnosed patients likely have worse outcomes than correctly diagnosed patients because they are at risk for complications of the initial stroke as well as recurrent events due to lack of secondary stroke prevention and failure to treat the underlying vascular pathology. Understanding important anatomic variants, the clinical presentations, relevant physical examination findings, and the limitations of acute brain imaging may help reduce misdiagnosis. We present a symptom-based review of posterior circulation ischemia focusing on the subtler presentations with a brief discussion of basilar stroke, both of which can be missed by the emergency physician. Strategies to avoid misdiagnosis include establishing an abrupt onset of symptoms, awareness of the nonspecific presentations, consideration of basilar stroke in altered patients and using a modern approach to diagnosis of the acutely dizzy patient.

['Stroke chameleons']

The diagnosis of acute stroke should be correct and early that allows physician planning the most effective treatment strategies (reperfusion therapy, undifferentiated (basic) treatment, early secondary prevention). However, stroke symptoms can be atypical and similar to some other (non-vascular) event. It can significantly complicate the clinical diagnosis of stroke and decrease the patient's chances for effective treatment. A stroke should be suspected in every patient with acute onset of neurological symptoms, especially when the patient has the 'vascular' risk factors. Furthermore it is important to remember that negative CT-scan data and/or MRI data do not exclude the presence of not only ischemic stroke but also hemorrhagic stroke. The article describes the main variants of strokes with atypical symptoms (strokes-chameleons), emphasizes the importance of careful clinical examination, provides supportive differential diagnostic criteria and discusses limitations of neuroimaging methods.

The Role of Neurosurgery in the Treatment of Intracranial Tumor-Like Inflammatory Lesions

BACKGROUND

Different inflammatory diseases can manifest as intracranial lesions. They may be indistinguishable from intracranial neoplasms in the clinical setting, imaging studies, or laboratory studies. The value of surgery in the diagnosis and the treatment of such lesions is still unclear.

METHODS

A total of 3066 reports of histopathologic examinations over a 10-year period were reviewed. Forty patients with an inflammatory intracranial lesion were identified. Clinical, radiologic, and follow-up data were analyzed and the diagnostic and therapeutic value of surgery was assessed.

RESULTS

We identified 24 women and 16 men (mean age, 47 years). The diameter of the lesion varied between 1 and 5.5 cm (mean, 2.6 cm). The location of the inflammatory lesion was intracerebral supratentorial (n = 18, 45%), intrasellar/suprasellar (n = 5, 12.5%), cerebellar (n = 5, 12.5%), in the brainstem (n = 4, 10%), in the cerebellopontine angle (n = 3, 7.5%), meningeal (n = 3, 7.5%), and at other locations (n = 6, 15%). Seventeen patients underwent surgical removal of the mass lesion, whereas in 23 patients a biopsy was taken. The lesions were classified into 7 groups: specific (infectious) granuloma (n = 10, 25%), unspecific granuloma (n = 7, 17.5%), idiopathic inflammatory pseudotumor (n = 5, 12.5%), demyelinating lesions (n = 5, 12.5%) encapsulated hematoma (n = 4, 10%), organized cerebral infarction (n = 3, 7.5%), and vasculitis (n = 4, 10%). Surgery was judged as valuable in 35 patients (87.5%).

CONCLUSIONS

The differential diagnosis of intracranial inflammatory lesions involves a wide spectrum. Surgery has a diagnostic and/or therapeutic value in most entities and clinical circumstances. However, attention must be taken to avoid surgery without a therapeutic or diagnostic value for the patient.

Artery of Percheron: an unusual stroke presentation

An 86-year-old woman was admitted with multiple episodes of transient loss of consciousness. She was initially treated for seizures, and stroke was not considered likely. MRI on the same day of admission showed acute bilateral medial thalamic infarcts in keeping with the Artery of Percheron (AOP) territory infarcts. Investigation for polycythaemia and thrombocytosis showed JAK2 positive myeloproliferative neoplasm.A diagnosis of AOP infarction is often missed or delayed because it is rare and presents with variable neurological symptoms. Initial imaging in the form of CT is often negative, and some report that initial MRI findings may also be normal.An awareness of a wide range of differential diagnoses alongside a multi-modality imaging approach is required to reach a diagnosis.Although there are several other case reports of AOP infarction in the literature, this is the first to present with transient symptoms initially mistaken for seizure activity.

Cryptogenic Stroke and Patent Foramen Ovale Risk Assessment

Stroke is a devastating condition. It is the fifth leading cause of death in the United States, and a leading cause of serious long-term disability. Stroke occurs at any age. Younger patients tend to have strokes of undetermined cause, termed cryptogenic. Herein, the authors describe the classification of stroke cause; the risk of recurrent cryptogenic stroke with patent foramen ovale (PFO); a risk assessment model to stratify incidental versus a pathogenic PFO in patients presenting with stroke; and patient selection for device occluder therapy in the context of the long-term follow-up of the RESPECT randomized clinical trial.

Psychiatric Hospitalization Increases Short-Term Risk of Stroke

BACKGROUND AND PURPOSE

Recent evidence suggests that psychological distress, including the symptoms of psychiatric illness, may acutely increase the risk of stroke. However, existing studies are limited by small sample sizes, inherent recall bias, and poorly defined criteria for what constitutes psychological distress.

METHODS

We analyzed administrative data from the Healthcare Cost and Utilization Project for the state of California from 2007 to 2009 using a case-crossover design. Conditional logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (95% CIs) for combined hemorrhagic and ischemic stroke risk occurring within 15, 30, 90, 180, and 365 days of a hospitalization for a psychiatric diagnosis (as defined by International Classification of Diseases, Ninth Revision, code) among adults.

RESULTS

Psychiatric hospitalizations within 1 year before stroke were found in 2585 (5.3%) of 48 558 stroke patients. Hospitalization for a psychiatric condition was associated with increased risk of stroke within all 5 time periods, with the highest odds of stroke occurring within 15 days (0-15 days: OR, 3.5; 95% confidence interval [CI], 2.6-4.8; 0-30 days: OR, 3.0; 95% CI, 2.4-3.8; 0-90 days: OR, 2.3; 95% CI, 2.0-2.7; 0-180 days: OR, 2.2; 95% CI, 2.0-2.5; and 0-365 days: OR, 2.6; 95% CI, 2.4-2.8).

CONCLUSIONS

Psychiatric hospitalization increases the short-term risk of stroke, particularly within the 15-day period after hospitalization.

Are We Overlooking Stroke Chameleons? A Retrospective Study on the Delayed Recognition of Stroke Patients

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.

Arterial Ischemic Stroke in Children and Young Adults

PURPOSE OF REVIEW

This article reviews risk factors, recurrence risk, evaluation, management, and outcomes of arterial ischemic stroke in children and young adults.

RECENT FINDINGS

The risk for recurrence and mortality appear to be low for neonatal and childhood stroke. Most children have relatively mild deficits, but those who have greater neurologic deficits, poststroke epilepsy, or strokes early in life are at risk for lower overall cognitive function. Stroke recurrence and long-term mortality after stroke in young adults are greater than originally thought. Cognitive impairments, depression, and anxiety are associated with higher levels of poststroke unemployment and represent targets for improved poststroke care. Poststroke care in young adults involves more than medical management. Self-reported memory and executive function impairments may be more severe than what is detected by objective measures. Assessment of possible cognitive impairments and appropriate management of psychological comorbidities are key to maximizing the long-term functional outcome of stroke survivors.

SUMMARY

Childhood and young adult stroke survivors survive for many more years than older patients with stroke. To ensure that these survivors maximize the productivity of their lives, neurologists must not only optimize medical management but also recognize that impairments in cognition and mood may be remediable barriers to long-term functional independence.

Mimics and chameleons in stroke

Ischaemic stroke is a treatable medical emergency. In an era of time-dependent reperfusion techniques, it is crucial that an accurate and prompt diagnosis is made. Approximately 30% of patients admitted to hyperacute stroke units are subsequently found not to have a final diagnosis of acute stroke although some of these patients do have incidental or previously symptomatic cerebrovascular disease. These patients do not benefit from thrombolysis and may require the input of other specialists or treatments. Meanwhile, a proportion of patients with acute stroke have unusual presentations and are sometimes initially admitted to general medical admissions units prior to accessing stroke unit care. It is important that atypical presentations of stroke are recognised so that patients are not denied the benefits of stroke unit care and secondary prevention. This article describes some characteristics of common stroke mimics and chameleons, considers how to avoid diagnostic mistakes and discusses the contributory role of imaging.

Treatment of Acute Ischemic Stroke

Although stroke declined from the third to fifth most common cause of death in the United States, the annual incidence and overall prevalence continue to increase. Since the available US Food and Drug Administration-approved treatment options are time dependent, improving early stroke care may have more of a public health impact than any other phase of care. Timely and efficient stroke treatment should be a priority for emergency department and prehospital providers. This article discusses currently available and emerging treatment options in acute ischemic stroke focusing on the preservation of salvageable brain tissue, minimizing complications, and secondary prevention.

Movement Disorders Following Cerebrovascular Lesions: Etiology, Treatment Options and Prognosis

Post-stroke movement disorders are uncommon, but comprise an important part of secondary movement disorders. These exert variable and heterogeneous clinical courses according to the stroke lesion and its temporal relationships. Moreover, the predominant stroke symptoms hinder a proper diagnosis in clinical practice. This article describes the etiology, treatment options and prognosis of post-stroke movement disorders.

[The differential diagnosis of recurrent episodes of vertigo]

Recurrent episodes of vertigo are one of the most frequent reasons of referrals for medical help. In the Russian medicine, the development of vertigo is traditionally associated with a cerebral vascular pathology. It is suggested that correctly planned clinical neurovestibular study may identify the signs of a balance disorder of peripheral and central genesis.

OBJECTIVE

To increase the effectiveness of the differential diagnosis of peripheral and central vertigo in patients with recurrent episodes of balance disorders using the protocol of neurovestibular examination ALGORITM.

MATERIAL AND METHODS

The study included 120 outpatients with preliminary diagnoses of cerebral ischemia and autonomic vascular dystonia.

RESULTS

Signs of lesion of peripheral and central regions of the vestibular system were found in 43.5 and 17.5% patients, respectively. Benign positional vertigo was the most frequent cause of vertigo while chronic cerebral ischemia was identified in 16.5% of the patients.

CONCLUSION

Neurovestibularexamnation using the protocol ALGORITM is important for assessment of the level of vestibular system lesion. Iitis necessary to use it in complex examination of patients with complaints of vertigo.

Movement Disorders Following Cerebrovascular Lesions in Cerebellar Circuits

Cerebellar circuitry is important to controlling and modifying motor activity. It conducts the coordination and correction of errors in muscle contractions during active movements. Therefore, cerebrovascular lesions of the cerebellum or its pathways can cause diverse movement disorders, such as action tremor, Holmes’ tremor, palatal tremor, asterixis, and dystonia. The pathophysiology of abnormal movements after stroke remains poorly understood. However, due to the current advances in functional neuroimaging, it has recently been described as changes in functional brain networks. This review describes the clinical features and pathophysiological mechanisms in different types of movement disorders following cerebrovascular lesions in the cerebellar circuits.

Hypertension unawareness among Chinese patients with first-ever stroke

Background

The low rates of hypertension treatment and control, partly due to its unawareness, are the main causes of the high stroke incidence in China. The purpose of this study was to evaluate hypertension unawareness amongst patients with first-ever stroke and to detect factors associated with its unawareness.

Methods

We selected those diagnosed with hypertension from patients with first-ever stroke registered in the Nanjing Stroke Registry Program between 2004 and 2014. These hypertensives were divided as being aware or unaware of their hypertension by using a brief questionnaire conducted shortly after the stroke. Multivariate logistic regression analysis was performed to identify potential factors associated with hypertension unawareness.

Results

Of the 5309 patients with first-ever stroke, 3732 (70.3 %) were diagnosed with hypertension. Among which, 593 (15.9 %) were unaware of their hypertension at the time of stroke onset. Lower-level of education (primary school or illiteracy) and smoking were associated positively with hypertension unawareness; while advanced age, overweight, diabetes mellitus, heart diseases and family history of stroke were associated negatively with hypertension unawareness. Annual data analyzed indicated that the rate of hypertension awareness increased during the past 11 years (r = 0.613, P = 0.045 for trends).

Conclusions

A substantial proportion (15.9 %) of Chinese patients with hypertension had not been aware of this covert risk until an overt stroke occurred. Hypertension unawareness was associated with lower educational levels and smoking, which address the importance of health education especially in these individuals.

Diagnosis of reversible causes of coma

Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. The first priority is to stabilise the patient by treatment of life-threatening conditions, then to use the history, physical examination, and laboratory findings to identify structural causes and diagnose treatable disorders. Some patients have a clear diagnosis. In those who do not, the first decision is whether brain imaging is needed. Imaging should be done in post-traumatic coma or when structural brain lesions are probable or possible causes. Patients who do not undergo imaging should be reassessed regularly. If CT is non-diagnostic, a checklist should be used use to indicate whether advanced imaging is needed or evidence is present of a treatable poisoning or infection, seizures including non-convulsive status epilepticus, endocrinopathy, or thiamine deficiency.

The golden hour Performing an acute ischemic stroke workup

Ischemic stroke is a medical emergency resulting from an embolic or thrombotic occlusion of an intracranial artery. The purpose of this article is to provide acute care nurse practitioners a summary of recent updates on the rapid evaluation and workup for patient selection and treatment with I.V. fibrinolysis.

Acute foot drop syndrome mimicking peroneal nerve injury: an atypical presentation of ischemic stroke

Foot drop syndrome is a frequent neurologic condition usually caused by peroneal nerve damage. On rare occasions, foot drop may present as the single neurologic manifestation of intracranial lesions. We presented a 43-year-old man admitted to our hospital with acute weakness in the dorsiflexion of his right foot that appeared 3 days before admission. Brain magnetic resonance imaging diffusion-weighted sequence revealed a small area of restricted diffusion in the left frontal cortex. Three months later, his motor deficit had completely improved (modified Rankin scale score = 0). To our knowledge, this is the second report of sudden isolated foot drop caused by a cortical infarction.

Recognition and management of stroke in young adults and adolescents

Approximately 15% of all ischemic strokes (IS) occur in young adults and adolescents. To date, only limited prior public health and research efforts have specifically addressed stroke in the young. Early diagnosis remains challenging because of the lack of awareness and the relative infrequency of stroke compared with stroke mimics. Moreover, the causes of IS in the young are heterogeneous and can be relatively uncommon, resulting in uncertainties about diagnostic evaluation and cause-specific management. Emerging data have raised public health concerns about the increasing prevalence of traditional vascular risk factors in young individuals, and their potential role in increasing the risk of IS, stroke recurrence, and poststroke mortality. These issues make it important to formulate and enact strategies to increase both awareness and access to resources for young stroke patients, their caregivers and families, and health care professionals. The American Academy of Neurology recently convened an expert panel to develop a consensus document concerning the recognition, evaluation, and management of IS in young adults and adolescents. The report of the consensus panel is presented herein.

Palatal tremor as a manifestation of epilepsia partialis continua caused by acute precentral gyral infarction

We describe a patient with palatal tremor (PT) as a manifestation of focal seizure caused by acute cortical infarction. Brain MRI showed acute infarction in the left precentral gyrus without evidence of brainstem lesions or hypertrophy of the inferior olivary nucleus. We discuss the differences between our patient and previous reports of symptomatic PT and the mechanisms involved in the development of PT associated with cortical lesions.

Avoiding misdiagnosis in patients with neurological emergencies

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.