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Barnett C, Mitchell C, Tyson S. The management of patients with functional stroke: speech and language therapists’ views and experiences. Disabil Rehabil 2021; 44:3547-3558. [DOI: 10.1080/09638288.2020.1867910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Caroline Barnett
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Claire Mitchell
- Division of Human Communication, Development & Hearing, University of Manchester, Manchester, UK
| | - Sarah Tyson
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
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2
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Ifergan H, Amelot A, Ismail M, Gaudron M, Cottier JP, Narata AP. Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:88-95. [PMID: 32159722 DOI: 10.1590/0004-282x20190154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/18/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND A larger therapeutic window for stroke treatment requires a significant change in the organization of emergency services, avoiding the increase in number of imaging exams and indirectly the time to treatment. OBJECTIVE To highlight the relation between faster clinical evaluation and stroke over-suspicion and consequently excessive imaging acquisition. To identify predictors of ischemic stroke and stroke mimics (SM), aiming for better patient selection for comprehensive neuroimaging and reperfusion therapies. METHODS Retrospective, cohort, observational, single-center study that reviewed all consecutive files of patients presenting with acute neurological symptoms who underwent CT scan or MRI from July 1, 2016 to July 1, 2017. RESULTS 736 patient files were reviewed. 385 patients (52.3%) presented with confirmed acute ischemic infarct, 93 (12.6%) had another brain lesion mimicking acute ischemia, and 258 (35.1%) had normal imaging. Acute stroke was more frequent in elderly patients with atrial fibrillation, arterial hypertension, or dysarthria or right motor impairment. Stroke mimic was associated with female patients with low vascular risk factors, low NIHSS, and patients with decreased level of consciousness or symptoms suggestive of posterior circulation. DISCUSSION 47.7% of all patients seen at the stroke unit did not have acute stroke lesions. Clinical assessment data have been used to provide indicators of acute stroke and stroke mimic patients, and symptoms corresponding to acute stroke and stroke mimic seem to be similar in the literature. CONCLUSION Considering that the number of patients admitted for stroke treatment will increase even further with a larger therapeutic window for mechanical thrombectomy and for thrombolysis, a diagnostic decision-making algorithm for stroke patients is required in order to reinforce the suspicion of stroke indicating an urgent MRI.
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Affiliation(s)
- Héloïse Ifergan
- Service de neuroradiologie diagnostique et interventionnelle, Centre Hospitalier Régional et Universitaire de Tours, France
| | - Aymeric Amelot
- Service de neurochirurgie, Centre Hospitalier Régional et Universitaire de Tours, France
| | - Mohammad Ismail
- Service de neuroradiologie diagnostique et interventionnelle, Centre Hospitalier Régional et Universitaire de Tours, France
| | - Marie Gaudron
- Service de neurologie vasculaire, Centre Hospitalier Régional et Universitaire de Tours, France
| | - Jean-Philippe Cottier
- Service de neuroradiologie diagnostique et interventionnelle, Centre Hospitalier Régional et Universitaire de Tours, France
| | - Ana Paula Narata
- Service de neuroradiologie diagnostique et interventionnelle, Centre Hospitalier Régional et Universitaire de Tours, France
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3
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Functional neurological disorders miming a stroke: management in the acute phase. Clin Neurol Neurosurg 2020; 196:105840. [DOI: 10.1016/j.clineuro.2020.105840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 11/18/2022]
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4
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Bacorn C, Fong NST, Lin LK. Misdiagnosis of Bell's palsy: Case series and literature review. Clin Case Rep 2020; 8:1185-1191. [PMID: 32695353 PMCID: PMC7364059 DOI: 10.1002/ccr3.2832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/28/2020] [Accepted: 03/15/2020] [Indexed: 11/08/2022] Open
Abstract
Although Bell's palsy is a common etiology for isolated facial paralysis, it is important clinicians perform a complete neurologic examination to avoid misdiagnosis. Multiple cranial neuropathy is often caused by tumor or infection.
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Affiliation(s)
- Colin Bacorn
- Department of Ophthalmology and Vision Science University of California Davis Health Sacramento CA USA
| | - Nancy Su Teng Fong
- University of California Davis School of Medicine University of California Davis Sacramento CA USA
| | - Lily Koo Lin
- Department of Ophthalmology and Vision Science University of California Davis Health Sacramento CA USA
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5
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Leys D, Moulin S, Goldstein P. Neurologists should not blame emergency physicians for stroke mimics, but train them to identify chameleons. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:61-62. [PMID: 31967215 DOI: 10.1590/0004-282x20190166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/28/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Didier Leys
- Université de Lille. Inserm U1171-1. CHU Lille. Lille, France
| | - Solène Moulin
- Université de Reims. CHU Reims. Neurologie. Reims, France
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6
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Simhan S, Thijs V, Mancuso S, Tsivgoulis G, Katsanos A, Alexandrov AV, Kanaan RA. The outcome of acute functional neurological disorder: a meta-analysis of stroke-mimic presentations. J Neurol 2020; 267:1353-1357. [DOI: 10.1007/s00415-020-09709-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/10/2020] [Accepted: 01/11/2020] [Indexed: 11/25/2022]
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7
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Toyoda K, Koga M, Iguchi Y, Itabashi R, Inoue M, Okada Y, Ogasawara K, Tsujino A, Hasegawa Y, Hatano T, Yamagami H, Iwama T, Shiokawa Y, Terayama Y, Minematsu K. Guidelines for Intravenous Thrombolysis (Recombinant Tissue-type Plasminogen Activator), the Third Edition, March 2019: A Guideline from the Japan Stroke Society. Neurol Med Chir (Tokyo) 2019; 59:449-491. [PMID: 31801934 PMCID: PMC6923159 DOI: 10.2176/nmc.st.2019-0177] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine
| | | | - Manabu Inoue
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center
| | | | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital
| | | | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital
| | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine
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8
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Holodinsky JK, Williamson TS, Demchuk AM, Zhao H, Zhu L, Francis MJ, Goyal M, Hill MD, Kamal N. Modeling Stroke Patient Transport for All Patients With Suspected Large-Vessel Occlusion. JAMA Neurol 2019; 75:1477-1486. [PMID: 30193366 DOI: 10.1001/jamaneurol.2018.2424] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance Ischemic stroke with large-vessel occlusion can be treated with alteplase and/or endovascular therapy; however, the administration of each treatment is time sensitive. Objective To identify the optimal triage and transport strategy: direct to the endovascular center (mothership) or immediate alteplase treatment followed by transfer to the endovascular center (drip and ship), for all patients with suspected large-vessel occlusion stroke. Design Setting, and Participants This was a theoretical, conditional probability modeling study. Existing data from clinical trials of stroke treatment were used for model generation. The study was conducted from February 1, 2017, to March 1, 2018. Main Outcomes and Measures The time-dependent efficacy of alteplase and endovascular therapy and the accuracy of large-vessel occlusion screening tools were modeled to estimate the probability of positive outcome (modified Rankin Scale score, 0-1 at 90 days) for both the drip-and-ship and mothership transport strategies. Based from onset to treatment, the strategy that estimates the greatest probability of excellent outcome is determined in several different scenarios. Results The patient's travel time from both thrombolysis and endovascular therapy centers, speed of treatment, and positive predictive value of the screening tool affect whether the drip-and-ship or mothership strategy estimates best outcomes. With optimal treatment times (door-to-needle time: 30 minutes; door-in-door-out time: 50 minutes; door-to-groin-puncture time: 60 minutes [mothership], 30 minutes [drip and ship]), both options estimate similar outcomes when the centers are 60 minutes or less apart. However, with increasing travel time between the 2 centers (90 or 120 minutes), drip and ship is favored if the patient would have to travel past the thrombolysis center to reach the endovascular therapy center or if the patient would arrive outside the alteplase treatment time window in the mothership scenario. Holding other variables constant, if treatment times are slow at the thrombolysis center (door-to-needle time: 60 minutes; door-in-door-out time: 120 minutes), the area where mothership estimates the best outcomes expands, especially when the 2 centers are close together (60 minutes apart or less). The area where mothership estimates the best outcome also expands as the positive predictive value of the screening tool increases. Conclusions and Relevance This study suggests that decision making for prehospital transport can be modeled using existing clinical trial data and that these models can be dynamically adapted to changing realities. Based on current median treatment times to realize the full benefit of endovascular therapy on a population level, the study findings suggest that delivery of the treatment should be regionally centralized. The study modeling suggests that transport decision making is context specific and the radius of superiority of the transport strategy changes based on treatment times at both centers, transport times, and the triaging tool used.
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Affiliation(s)
- Jessalyn K Holodinsky
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tyler S Williamson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew M Demchuk
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Henry Zhao
- Department of Medicine and Neurology, Royal Melbourne Hospital, Parkville, Australia
| | - Luke Zhu
- Student, Department of Chemical and Petroleum Engineering, Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Francis
- Student, Department of Mechanical and Manufacturing Engineering, Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Calgary Stroke Program, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Noreen Kamal
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Electrical and Computer Engineering, Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada.,Department of Mechanical and Manufacturing Engineering, Schulich School of Engineering, University of Calgary, Calgary, Alberta, Canada
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Ali-Ahmed F, Federspiel JJ, Liang L, Xu H, Sevilis T, Hernandez AF, Kosinski AS, Prvu Bettger J, Smith EE, Bhatt DL, Schwamm LH, Fonarow GC, Peterson ED, Xian Y. Intravenous Tissue Plasminogen Activator in Stroke Mimics. Circ Cardiovasc Qual Outcomes 2019; 12:e005609. [PMID: 31412730 PMCID: PMC6699639 DOI: 10.1161/circoutcomes.119.005609] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The necessity for rapid evaluation and treatment of acute ischemic stroke with intravenous tPA (tissue-type plasminogen activator) may increase the risk of administrating tPA to patients presenting with noncerebrovascular conditions that closely resemble stroke (stroke mimics). However, there are limited data on thrombolysis safety in stroke mimics. METHODS AND RESULTS Using data from the Get With The Guidelines-Stroke Registry, we identified 72 582 patients with suspected ischemic stroke treated with tPA from 485 US hospitals between January 2010 and December 2017. We documented the use of tPA in stroke mimics, defined as patients who present with stroke-like symptoms, but after workup are determined not to have suffered from a stroke or transient ischemic attack, and compared characteristics and outcomes in stroke mimics versus those with ischemic stroke. Overall, 3.5% of tPA treatments were given to stroke mimics. Among them, 38.2% had a final nonstroke diagnoses of migraine, functional disorder, seizure, and electrolyte or metabolic imbalance. Compared with tPA-treated true ischemic strokes, tPA-treated mimics were younger (median 54 versus 71 years), had a less severe National Institute of Health Stroke Scale (median 6 versus 8), and a lower prevalence of cardiovascular risk factors, except for a higher prevalence of prior stroke/transient ischemic attack (31.3% versus 26.1%, all P<0.001). The rate of symptomatic intracranial hemorrhage was lower in stroke mimics (0.4%) as compared with 3.5% in ischemic strokes (adjusted odds ratio, 0.29; 95% CI, 0.17-0.50). In-hospital mortality rate was significantly lower in stroke mimics (0.8% versus 6.2%, adjusted odds ratio, 0.31; 95% CI, 0.20-0.49). Patients with stroke mimics were more likely to be discharged to home (83.8% versus 49.3%, adjusted odds ratio, 2.97; 95% CI, 2.59-3.42) and to ambulate independently at discharge (78.6% versus 50.6%, adjusted odds ratio, 1.86; 95% CI, 1.61-2.14). CONCLUSIONS In this large cohort of patients treated with tPA, relatively few patients who received tPA for presumed stroke were ultimately not diagnosed with a stroke or transient ischemic attack. The complication rates associated with tPA in stroke mimics were low. Despite the potential risk of administering tPA to stroke mimics, opportunity remains for continued improvement in the rapid and accurate diagnosis and treatment of ischemic stroke.
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Affiliation(s)
- Fatima Ali-Ahmed
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.).,Department of Cardiology, Beaumont Health, Dearborn, MI (F.A.-A.)
| | - Jerome J Federspiel
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.)
| | - Li Liang
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Haolin Xu
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Theresa Sevilis
- Department of Neurology, Duke University Medical Center, Durham, NC (T.S., Y.X.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Janet Prvu Bettger
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Alberta, CA (E.E.S.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Lee H Schwamm
- Division of Neurology, Massachusetts General Hospital, Boston, MA (L.H.S.)
| | - Gregg C Fonarow
- Division of Cardiology, University of California, LA (G.C.F.)
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.)
| | - Ying Xian
- Duke Clinical Research Institute, Durham, NC (F.A.-A., L.L., H.X., A.F.H., A.S.K., J.P.B., E.D.P., Y.X.).,Department of Neurology, Duke University Medical Center, Durham, NC (T.S., Y.X.)
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10
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Barnett C, Armes J, Smith C. Speech, language and swallowing impairments in functional neurological disorder: a scoping review. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2019; 54:309-320. [PMID: 30592118 DOI: 10.1111/1460-6984.12448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/27/2018] [Accepted: 12/04/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Functional neurological disorder (FND) is common across healthcare settings. The Diagnostic and Statistical Manual of Mental Disorders states that speech and swallowing symptoms can be present in FND. Despite this, there is a dearth of guidelines for speech and language therapists (SLTs) for this client group. AIMS To address the following question in order to identify gaps for further research: What is known about speech, language and swallowing symptoms in patients with FND? METHODS & PROCEDURES A scoping review was conducted. Six healthcare databases were searched for relevant literature: CINAHL PLUS, MEDLINE, ProQuest Nursing and Allied Health Professionals, Science Citation Index, Scopus, and PsychINFO. The following symptoms were excluded from the review: dysphonia, globus pharyngeus, dysfluency, foreign accent syndrome and oesophageal dysphagia. MAIN CONTRIBUTION A total of 63 papers were included in the final review; they ranged in date from 1953 to 2018. Case studies were the most frequent research method (n = 23, 37%). 'Psychogenic' was the term used most frequently (n = 24, 38%), followed by 'functional' (n = 21, 33%). Speech symptoms were reported most frequently (n = 41, 65%), followed by language impairments (n = 35, 56%) and dysphagia (n = 13, 21%). Only 11 publications comment on the involvement of SLTs. Eight papers report direct speech and language therapy input; however, none studied the effectiveness of speech and language therapy. CONCLUSIONS & IMPLICATIONS Speech, language and swallowing symptoms do occur in patients with FND, yet it is a highly under-researched area. Further research is required to create a set of positive diagnostic criteria, gather accurate data on numbers of patients with FND and speech, language or swallowing symptoms, and to evaluate the effectiveness of direct speech and language therapy involvement.
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Affiliation(s)
- Caroline Barnett
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jean Armes
- Birmingham Community Healthcare NHS Trust, Birmingham, UK
| | - Christina Smith
- Department of Language and Cognition, University College London, London, UK
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11
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Armon C, Wainstein J, Gour A, Levite R, Bartal A, Kriboushay A, Kenan G, Khiri F, Shevtzov E, Aroesty R, Bhonkar S, Tal S, Ilgiyaev E, Blatt A, Haitov Z, Bar-Hayim S, Kimiagar I. CT-guided thrombolytic treatment of patients with wake-up strokes. eNeurologicalSci 2019; 14:91-97. [PMID: 30828649 PMCID: PMC6378852 DOI: 10.1016/j.ensci.2019.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/04/2019] [Indexed: 11/16/2022] Open
Abstract
Background Observational studies of thrombolysis outcomes in wake-up acute ischemic stroke patients selected based on non-contrast brain CT criteria suggested that treated patients did as well as or better than those not treated, after adjustment for baseline characteristics. We began offering thrombolytic treatment (IVTPA) to patients presenting with wake-up strokes and normal non-contrast brain CTs, who could be treated within 4.5 h of being found. Design/methods A retrospective chart review was performed in patients presenting with AIS between November 2014 and December 2017 who received IVTPA. A planned subgroup analysis compared patients with wake-up strokes and normal non-contrast brain CTs to patients with witnessed stroke treated within 4.5 h of being found, or of witnessed onset, respectively. Results Three hundred and six patients were treated, 279 with witnessed-onset and 27 with wake-up strokes. The latter were not candidates for endovascular intervention. Efficacy and safety were similar in both groups. Discharges home, respectively, were 143(53%) and 13(48%); facility discharges were 112(40.1%) and 11(40.7%) and in-hospital mortality was 19 (6.8%) and 3 (11%). Treatment-related symptomatic bleeds were: 5(1.8%) and 1 (3.7%), respectively. Conclusions The findings affirm, in a new clinical series reflecting routine practice, that it is safe to treat with IVTPA patients with wake-up strokes and a normal brain CT scan, who are not candidates for endovascular intervention. We hypothesize, that when the non-contrast brain CT scan is normal, it may be safe to extend beyond 4.5 h the IVTPA treatment eligibility window in similar patients with witnessed-onset stroke.
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Affiliation(s)
- Carmel Armon
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Jochay Wainstein
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Aviv Gour
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Levite
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Avigail Bartal
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Angela Kriboushay
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Gilad Kenan
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Fikri Khiri
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Evelina Shevtzov
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Rina Aroesty
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Sarah Bhonkar
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Sigal Tal
- Departments of Radiology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Eduard Ilgiyaev
- Departments of Intensive Care, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Alex Blatt
- Departments of Cardiac Intensive Care, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Zoya Haitov
- Departments of Anesthesiology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Samuel Bar-Hayim
- Departments of Emergency Medicine, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Itzhak Kimiagar
- Departments of Neurology, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel.,Departments of Intensive Care, Sackler Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Tel Aviv University, Tel Aviv, Israel
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12
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Terrin A, Toldo G, Ermani M, Mainardi F, Maggioni F. When migraine mimics stroke: A systematic review. Cephalalgia 2018; 38:2068-2078. [PMID: 29661036 DOI: 10.1177/0333102418767999] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Migraine with aura may mimic an acute ischemic stroke, so that an improper administration of thrombolytic treatment can expose migrainous patients to severe adverse effects. METHODS This systematic review quantifies the relevance of migraine with aura among stroke mimics, checking for thrombolysis' safety in these patients. We reviewed the literature after 1995, distinguishing from studies dealing with stroke mimics treated with systemic thrombolysis and those who were not treated with systemic thrombolysis. RESULTS Migraine with aura is responsible for 1.79% (CI 95% 0.82-3.79%) of all the emergency Stroke Unit evaluations and it represents 12.24% (CI 95% 6.34-22.31%) of stroke mimics in the group not treated with systemic thrombolysis. 6.65% (CI 95% 4.32-9.78%) of systemic thrombolysis administrations are performed in patients without an acute ischemic stroke. Migraine with aura is responsible for 17.91% of these (CI 95% 13.29-23.71%). The reported rate of adverse events seems extremely low (0.01%). CONCLUSION Migraine with aura is the third most common stroke mimic, following seizures and psychiatric disorders; it is responsible for about 18% of all improper thrombolytic treatments. Despite the absence of strong supporting data, thrombolysis in migraine with aura seems to be a procedure with an extremely low risk of adverse events.
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Affiliation(s)
- Alberto Terrin
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | - Giulia Toldo
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | - Mario Ermani
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
| | | | - Ferdinando Maggioni
- 1 Headache Centre, Department of Neuroscience, University of Padova, Padova, Italy
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13
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Ridolfi M, Granato A, Polverino P, Furlanis G, Ukmar M, Zorzenon I, Manganotti P. Migrainous aura as stroke-mimic: The role of perfusion-computed tomography. Clin Neurol Neurosurg 2018; 166:131-135. [DOI: 10.1016/j.clineuro.2018.01.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 01/11/2018] [Accepted: 01/28/2018] [Indexed: 10/18/2022]
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Olindo S, Chardonnet M, Renou P, Coignion C, Debruxelles S, Poli M, Sagnier S, Rouanet F, Sibon I. Clinical Predictors of Stroke Mimics in Patients Treated with Recombinant Tissue Plasminogen Activator according to a Normal Multimodal Computed Tomography Imaging. J Stroke Cerebrovasc Dis 2017; 27:454-459. [PMID: 29128327 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/24/2017] [Accepted: 09/18/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Multimodal computed tomography imaging (MCTI) is increasingly used for rapid assessment of acute stroke. We investigated characteristics and final diagnoses of patients treated with recombinant tissue plasminogen activator (rt-PA) while admission imaging was unremarkable. METHODS From our prospectively collected stroke database (2013-2016), we identified consecutive patients treated with rt-PA on the basis of an unremarkable brain MCTI and assessed with a 24-hour follow-up brain magnetic resonance imaging (MRI). Demographic data, medical history, score on the 15-item National Institute of Health Stroke Scale, and final diagnosis were considered. Absence of MRI infarction and alternate diagnosis defined stroke mimics (SMs). Univariable and multivariable logistic regression analyses identified factors predictive of SMs. RESULTS Sixty-eight (47.9%) SMs, 63 (44.4%) strokes, and 11 (7.7%) aborted strokes were found. SMs had more often aphasia (P = .003) and hemianopia (P = .0008), whereas upper limb weakness (ULW) (P = .03) and limb ataxia (P = .002) were more prevalent in strokes. Headache (adjusted odds ratio [Adj. OR], 3.89 [95% confidence interval {CI} 1.44-10.47]), relevant history of epilepsy, migraine, dementia or depression (Adj. OR 3.66 [95% CI 1.31-10.18]), unilateral sensory loss (Adj. OR 2.60 [95% CI 1.05-6.45]), and hemianopia (Adj. OR 4.94 [95% CI 1.46-16.77]) were independent predictors of SMs whereas ULW (Adj. OR 3.16 [95% CI 1.28-7.82]) and ataxia (Adj. OR 3.81 [95% CI 1.43-10.13]) predicted stroke. Sensitivity of hemianopia or aphasia for SMs was 52.9%, with specificity of 84.1%, positive predictive value of 78.3%, and negative predictive value of 62.4%. CONCLUSIONS Hemianopia and/or aphasia with normal MCTI suggest SMs. Diffusion-weighted MRI might be discussed before rt-PA administration in patients with such a clinical pattern.
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Affiliation(s)
| | | | - Pauline Renou
- Department of Neurology, CHU de Bordeaux, Bordeaux, France
| | | | | | - Mathilde Poli
- Department of Neurology, CHU de Bordeaux, Bordeaux, France
| | | | | | - Igor Sibon
- Department of Neurology, CHU de Bordeaux, Bordeaux, France
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15
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Kostulas N, Larsson M, Kall TB, von Euler M, Nathanson D. Safety of thrombolysis in stroke mimics: an observational cohort study from an urban teaching hospital in Sweden. BMJ Open 2017; 7:e016311. [PMID: 29084788 PMCID: PMC5665231 DOI: 10.1136/bmjopen-2017-016311] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES Acute stroke management has changed dramatically over the recent years, where a timely assessment is driven by the expanding treatment options of acute ischaemic stroke. This increases the risk in treating non-stroke patients (stroke mimics) with a possibly hazardous intravenous thrombolysis treatment (IVT). SETTING Patients of the thrombolysis registry of Södersjukhuset AB, a secondary health centre in Stockholm, were retrospectively studied to determine complications and outcome after IVT in strokes and stroke mimics. PARTICIPANTS Consecutively, 674 recruited patients from 1 January 2008 to 1 December 2013 were analysed regarding demographics and outcome at 3 months after onset of symptoms. RESULTS Ischaemic stroke was confirmed in 625 patients (93%), and 48 patients (7%) were stroke mimics. Patients with strokes were older than stroke mimics 72 (IQR: 64-81) vs 54 years (IQR 40-67), p<0.0001. Antihypertensive and antithrombotic treatment were more common in patients with stroke (p<0.0001 and p=0.006, respectively). National Institute of Health Stroke Scale did not differ at time of presentation. Excellent outcome defined as modified Rankin Scale score 0-1, at 3 months, was less common in stroke than in stroke mimics (50% vs 87.5%, p<0.0001). No stroke mimic had a symptomatic intracerebral haemorrhage. Age of less than 40 years may be a predictor for a patient to be a stroke mimic (OR: 8.7, 95% CI: 3.2 to 24.0, p<0.0001). CONCLUSIONS Stroke mimics receiving IVT had a more favourable outcome compared with patients with stroke, and showed no haemorrhagic complications. Age below 40 years may be a predictor for stroke mimics.
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Affiliation(s)
- Nikolaos Kostulas
- Depatment of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Martin Larsson
- Depatment of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Tor-Bjorn Kall
- Depatment of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
| | - Mia von Euler
- Depatment of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Karolinska Institutet Stroke Research Network, Stockholm, Sweden
| | - David Nathanson
- Depatment of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
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16
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Prabhakaran S, Khorzad R, Brown A, Nannicelli AP, Khare R, Holl JL. Academic-Community Hospital Comparison of Vulnerabilities in Door-to-Needle Process for Acute Ischemic Stroke. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2016; 8:S148-54. [PMID: 26515203 DOI: 10.1161/circoutcomes.115.002085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although best practices have been developed for achieving door-to-needle (DTN) times ≤60 minutes for stroke thrombolysis, critical DTN process failures persist. We sought to compare these failures in the Emergency Department at an academic medical center and a community hospital. METHODS AND RESULTS Failure modes effects and criticality analysis was used to identify system and process failures. Multidisciplinary teams involved in DTN care participated in moderated sessions at each site. As a result, DTN process maps were created and potential failures and their causes, frequency, severity, and existing safeguards were identified. For each failure, a risk priority number and criticality score were calculated; failures were then ranked, with the highest scores representing the most critical failures and targets for intervention. We detected a total of 70 failures in 50 process steps and 76 failures in 42 process steps at the community hospital and academic medical center, respectively. At the community hospital, critical failures included (1) delay in registration because of Emergency Department overcrowding, (2) incorrect triage diagnosis among walk-in patients, and (3) delay in obtaining consent for thrombolytic treatment. At the academic medical center, critical failures included (1) incorrect triage diagnosis among walk-in patients, (2) delay in stroke team activation, and (3) delay in obtaining computed tomographic imaging. CONCLUSIONS Although the identification of common critical failures suggests opportunities for a generalizable process redesign, differences in the criticality and nature of failures must be addressed at the individual hospital level, to develop robust and sustainable solutions to reduce DTN time.
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Affiliation(s)
- Shyam Prabhakaran
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.).
| | - Rebeca Khorzad
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.)
| | - Alexandra Brown
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.)
| | - Anna P Nannicelli
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.)
| | - Rahul Khare
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.)
| | - Jane L Holl
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.)
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17
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Guillan M, DeFelipe-Mimbrera A, Alonso-Canovas A, Matute MC, Vera R, Cruz-Culebras A, Garcia-Barragan N, Masjuan J. The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis mimicking an acute stroke. Eur J Neurol 2016; 23:1235-40. [PMID: 27105768 DOI: 10.1111/ene.13008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 03/02/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) can present as sudden onset of focal neurological deficits which are clinically and radiologically indistinguishable from an ischaemic stroke. Its diagnosis requires a lumbar puncture (LP), which contraindicates intravenous thrombolytic therapy (IV-tPA). METHODS All patients referred to our stroke centre as a stroke code resulting in a final diagnosis of HaNDL syndrome from June 2005 to June 2015 were retrospectively analysed. RESULTS Nine cases were identified: seven women and two men (mean age 27.6 years, range 15-51). Clinical onset consisted of isolated aphasia (two) and aphasia with right hemiparesis/hemiparaesthesia (seven). All patients had headache in the acute setting, lasting 2-12 h. Cranial computed tomography (CT) and CT angiography (CTA) were normal in all patients. Perfusion CT was performed in seven patients, showing left hemispheric focal hypoperfusion in five cases; the remaining two were normal. Five patients were initially diagnosed as stroke and treated uneventfully with IV-tPA. Cranial magnetic resonance imaging within 48 h was normal in all cases. LP performed in all patients showed pleocytosis (range 17-351 cells/mm(3) ), high protein levels (range 0.4-1.6 g/l) and normal glucose levels. All cases recovered within 12 h and suffered a second episode within 72 h. Patients were asymptomatic between episodes and after remission. CONCLUSIONS The decision to thrombolyse or perform an LP in HaNDL patients mimicking a stroke is difficult in the acute setting. Perfusion CT can provide misleading results and CTA may be useful in ruling out occlusion of a cerebral vessel.
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Affiliation(s)
- M Guillan
- Stroke Unit, Department of Neurology, IRYCIS, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - A DeFelipe-Mimbrera
- Stroke Unit, Department of Neurology, IRYCIS, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - A Alonso-Canovas
- Stroke Unit, Department of Neurology, IRYCIS, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - M C Matute
- Stroke Unit, Department of Neurology, IRYCIS, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - R Vera
- Stroke Unit, Department of Neurology, IRYCIS, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - A Cruz-Culebras
- Stroke Unit, Department of Neurology, IRYCIS, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - N Garcia-Barragan
- Stroke Unit, Department of Neurology, IRYCIS, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - J Masjuan
- Stroke Unit, Department of Neurology, IRYCIS, Hospital Universitario Ramon y Cajal, Madrid, Spain.,Universidad de Alcala de Henares, Madrid, Spain
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18
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Sivakumaran P, Gill D, Mahir G, Baheerathan A, Kar A. A Retrospective Cohort Study on the Use of Intravenous Thrombolysis in Stroke Mimics. J Stroke Cerebrovasc Dis 2016; 25:1057-1061. [PMID: 26856459 DOI: 10.1016/j.jstrokecerebrovasdis.2016.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 01/03/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The urgency of intravenous thrombolysis in acute ischemic stroke can lead to inadvertent thrombolysis of patients with nonstroke diagnoses (stroke mimics), increasing the risk of adverse events. The objectives of this study were to compare thrombolysed acute ischemic stroke and stroke mimic cases based on demographic factors, physiological parameters, radiological findings, and clinical presentation, and to evaluate the clinical implications of thrombolysing stroke mimics. METHODS A retrospective analysis of a single-center database of all thrombolysed strokes and mimics over a period greater than 3 years. Diagnoses were confirmed by expert consensus after a review of clinical factors and imaging. Intercohort variation was assessed using Wilcoxon rank-sum or Pearson's chi-square test. RESULTS The stroke mimic cohort tended to be younger (mean age 59.9 years versus 73.7 years, P < .001) and had a lower National Institutes of Health Stroke Score at presentation (mean 5.9 points versus 6.4 points, P < .01). However, the time taken from the onset of symptoms to delivery of thrombolytic drugs was longer in the mimic cohort (mean time 170 minutes versus 138 minutes, P < .01). Any differences in blood glucose (P = .07), time taken from hospital arrival to delivery of intravenous thrombolysis (P = .57), and blood pressure on admission (systolic, P = .09 and diastolic, P = .34) were not statistically significant. No adverse events were reported in the mimic cohort. CONCLUSION Despite similarities in clinical presentation, thrombolysed stroke mimics are of a different physiological and demographic population, and are associated with fewer adverse events compared with thrombolysed acute ischemic stroke patients.
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Affiliation(s)
| | - Dipender Gill
- Imperial College Healthcare NHS Trust, London, UK; Imperial College London, London, UK.
| | - Gheed Mahir
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Arindam Kar
- Imperial College Healthcare NHS Trust, London, UK
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19
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Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke 2016; 47:581-641. [DOI: 10.1161/str.0000000000000086] [Citation(s) in RCA: 442] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods—
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results—
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
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20
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Lorenz MW, Lauer A, Foerch C. Quantifying the Benefit of Prehospital Rapid Treatment in Acute Stroke. Stroke 2015; 46:3168-76. [DOI: 10.1161/strokeaha.115.010445] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/12/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In acute ischemic stroke, time from onset to tissue-type plasminogen activator treatment (OTT) is a major determinant of outcome. To reduce OTT, clinical trials have been undertaken evaluating prehospital cerebral imaging with mobile computed tomographic scanners. Furthermore, blood biomarkers may allow rapid differentiation between ischemic stroke and intracerebral hemorrhage before hospital admission. How such treatment strategies translate into clinical benefit has not been specifically evaluated.
Methods—
We constructed decision models to estimate the net clinical benefit yielded by shorter OTT. In different scenarios, we estimated the proportion of patients with favorable outcome and the average quality of life.
Results—
An OTT reduction of 60 minutes increases the probability of favorable outcome by 6.6% in a mixed stroke population. For comparison, the average effect of tissue-type plasminogen activator itself is 7.0%. Prehospital mobile computed tomography gaining 25 to 40 minutes increases the probability of favorable outcome by 3.0% to 4.6%. The additional benefit of prehospital computed tomography to deliver patients with large vessel occlusion directly to endovascular treatment centers increases the probability of favorable outcome by another 0.2% to 1.0%. A blood test discriminating ischemic stroke and intracerebral hemorrhage may beneficially substitute brain scan before tissue-type plasminogen activator if >32 to 40 minutes are gained and if sensitivity for intracerebral hemorrhage is >75% to 80%.
Conclusions—
Reducing the OTT has robust beneficial effects for acute stroke patients. Prehospital tissue-type plasminogen activator treatment without brain imaging may become conceivable under several preconditions, including a point-of-care test with >75% to 80% sensitivity to detect intracerebral hemorrhage and a time gain of >32 to 40 minutes. Ethical implications remain to be addressed.
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Affiliation(s)
- Matthias W. Lorenz
- From the Department of Neurology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Arne Lauer
- From the Department of Neurology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Christian Foerch
- From the Department of Neurology, University Hospital Frankfurt, Frankfurt/Main, Germany
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21
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Tsivgoulis G, Zand R, Katsanos AH, Goyal N, Uchino K, Chang J, Dardiotis E, Putaala J, Alexandrov AW, Malkoff MD, Alexandrov AV. Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis. Stroke 2015; 46:1281-7. [PMID: 25791717 DOI: 10.1161/strokeaha.115.009012] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 02/25/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Shortening door-to-needle time may lead to inadvertent intravenous thrombolysis (IVT) administration in stroke mimics (SMs). We sought to determine the safety of IVT in SMs using prospective, single-center data and by conducting a comprehensive meta-analysis of reported case-series. METHODS We prospectively analyzed consecutive IVT-treated patients during a 5-year period at a tertiary care stroke center. A systematic review and meta-analysis of case-series reporting safety of IVT in SMs and confirmed acute ischemic stroke were conducted. Symptomatic intracerebral hemorrhage was defined as imaging evidence of ICH with an National Institutes of Health Stroke scale increase of ≥4 points. Favorable functional outcome at hospital discharge was defined as a modified Rankin Scale score of 0 to 1. RESULTS Of 516 consecutive IVT patients at our tertiary care center (50% men; mean age, 60±14 years; median National Institutes of Health Stroke scale, 11; range, 3-22), SMs comprised 75 cases. Symptomatic intracerebral hemorrhage occurred in 1 patient, whereas we documented no cases of orolingual edema or major extracranial hemorrhagic complications. In meta-analysis of 9 studies (8942 IVT-treated patients), the pooled rates of symptomatic intracerebral hemorrhage and orolingual edema among 392 patients with SM treated with IVT were 0.5% (95% confidence interval, 0%-2%) and 0.3% (95% confidence interval, 0%-2%), respectively. Patients with SM were found to have a significantly lower risk for symptomatic intracerebral hemorrhage compared with patients with acute ischemic stroke (risk ratio=0.33; 95% confidence interval, 0.14-0.77; P=0.010), with no evidence of heterogeneity or publication bias. Favorable functional outcome was almost 3-fold higher in patients with SM in comparison with patients with acute ischemic stroke (risk ratio=2.78; 95% confidence interval, 2.07-3.73; P<0.00001). CONCLUSIONS Our prospective, single-center experience coupled with the findings of the comprehensive meta-analysis underscores the safety of IVT in SM.
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Affiliation(s)
- Georgios Tsivgoulis
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Ramin Zand
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Aristeidis H Katsanos
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Nitin Goyal
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Ken Uchino
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Jason Chang
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Efthimios Dardiotis
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Jukka Putaala
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Anne W Alexandrov
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Marc D Malkoff
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
| | - Andrei V Alexandrov
- From the Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T., R.Z., N.G., J.C., A.W.A., M.D.M., A.V.A.); Second Department of Neurology, "Attikon University Hospital," School of Medicine, University of Athens, Athens, Greece (G.T., A.H.K.); Department of Neurology, Cerebrovascular Center, Cleveland Clinic, OH (K.U.); Department of Neurology, University Hospital of Larissa, University of Thessaly, Larissa, Greece (E.D.); Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland (J.P.); and College of Nursing, Australian Catholic University, Sydney, New South Wales, Australia (A.W.A.)
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Kim WJ, Paik NJ. Lesion localization of global aphasia without hemiparesis by overlapping of the brain magnetic resonance images. Neural Regen Res 2015; 9:2081-6. [PMID: 25657725 PMCID: PMC4316473 DOI: 10.4103/1673-5374.147935] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2014] [Indexed: 11/10/2022] Open
Abstract
Global aphasia without hemiparesis is a striking stroke syndrome involving language impairment without the typically manifested contralateral hemiparesis, which is usually seen in patients with global aphasia following large left perisylvian lesions. The objective of this study is to elucidate the specific areas for lesion localization of global aphasia without hemiparesis by retrospectively studying the brain magnetic resonance images of six patients with global aphasia without hemiparesis to define global aphasia without hemiparesis-related stroke lesions before overlapping the images to visualize the most overlapped area. Talairach coordinates for the most overlapped areas were converted to corresponding anatomical regions. Lesions where the images of more than three patients overlapped were considered significant. The overlapped global aphasia without hemiparesis related stroke lesions of six patients revealed that the significantly involved anatomical lesions were as follows: frontal lobe, sub-gyral, sub-lobar, extra-nuclear, corpus callosum, and inferior frontal gyrus, while caudate, claustrum, middle frontal gyrus, limbic lobe, temporal lobe, superior temporal gyrus, uncus, anterior cingulate, parahippocampal, amygdala, and subcallosal gyrus were seen less significantly involved. This study is the first to demonstrate the heterogeneous anatomical involvement in global aphasia without hemiparesis by overlapping of the brain magnetic resonance images.
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Affiliation(s)
- Woo Jin Kim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea ; Department of Physical Medicine and Rehabilitation, Haeundae Paik Hospital, Inje University of Medicine, Busan, South Korea
| | - Nam-Jong Paik
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea ; Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, South Korea
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MR screening of candidates for thrombolysis: How to identify stroke mimics? J Neuroradiol 2014; 41:283-95. [PMID: 25451670 DOI: 10.1016/j.neurad.2014.05.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 05/24/2014] [Accepted: 05/26/2014] [Indexed: 11/21/2022]
Abstract
Stroke mimics account for up to a third of suspected strokes. The main causes are epileptic deficit, migraine aura, hypoglycemia, and functional disorders. Accurate recognition of stroke mimics is important for adequate identification of candidates for thrombolysis. This decreases the number of unnecessary treatments and invasive vascular investigations. Correctly identifying the cause of symptoms also avoids delaying proper care. Therefore, this pictorial review focuses on what the radiologist should know about the most common MRI patterns of stroke mimics in the first hours after onset of symptoms. The issues linked to the accurate diagnosis of stroke mimics in the management of candidates for thrombolysis will be discussed.
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24
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Sattin JA. Telephone consultations for tissue plasminogen activator administration in acute stroke. Continuum (Minneap Minn) 2014; 20:429-35. [PMID: 24699491 PMCID: PMC10563925 DOI: 10.1212/01.con.0000446111.97667.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Effective treatment for acute ischemic stroke has been available for 17 years, but wide geographic variability remains in timely access to neurologic expertise and other components of stroke systems of care. Telemedical technology can be used to improve such access, but it is debatable whether neurologists have an ethical obligation to provide consultation regarding tissue plasminogen activator use via the telephone. This article examines whether neurologists are ethically obligated to provide telephone-mediated acute stroke consultation.
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Stroke mimics under the drip-and-ship paradigm. J Stroke Cerebrovasc Dis 2013; 23:844-9. [PMID: 23954600 DOI: 10.1016/j.jstrokecerebrovasdis.2013.07.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 06/28/2013] [Accepted: 07/07/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. We hypothesized that a higher rate of stroke mimics (SM) among AIS treated in nonspecialized stroke centers that are transferred to comprehensive centers is responsible for such outcomes. METHODS Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over 1 academic year (July 1, 2011 to June 30, 2012). Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge disposition was collected. We identified those patients who were treated at a facility and then transferred to the tertiary center (ie, drip-and-ship paradigm). In addition to comparative and adjusted analysis to identify predictors for SM, a stratified analysis by the drip-and-ship status was performed. RESULTS One hundred twenty patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = .0003) and more likely to harbor psychiatric diagnoses (45% versus 9%; P ≤ .0001). Eighteen of 20 SM patients (90%) had the drip-and-ship treatment paradigm compared with 65% of those with AIS (P = .02). None of the SM had hemorrhagic complications, and all were discharged to home. Predictors of SM on adjusted analysis included the drip-and-ship paradigm (odds ratio [OR] 12.8, 95% confidence interval [CI] 1.78, 92.1) and history of any psychiatric illness (OR 12.08; 95% CI 3.14, 46.4). Eighteen of 83 drip-and-ship patients (21.7%) were diagnosed with SM compared with 2 of 37 patients (5.4%) presented directly to the hub hospital (P = .02). CONCLUSION The drip-and-ship paradigm and any psychiatric history predict the diagnosis of SM. None of the SM had thrombolysis-related complications, and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment for AIS.
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Minematsu K, Toyoda K, Hirano T, Kimura K, Kondo R, Mori E, Nakagawara J, Sakai N, Shiokawa Y, Tanahashi N, Yasaka M, Katayama Y, Miyamoto S, Ogawa A, Sasaki M, Suga S, Yamaguchi T. Guidelines for the intravenous application of recombinant tissue-type plasminogen activator (alteplase), the second edition, October 2012: a guideline from the Japan Stroke Society. J Stroke Cerebrovasc Dis 2013; 22:571-600. [PMID: 23727456 DOI: 10.1016/j.jstrokecerebrovasdis.2013.04.001] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 04/05/2013] [Indexed: 12/31/2022] Open
Abstract
In Japan, intravenous alteplase, a recombinant tissue-type plasminogen activator (rt-PA), was approved for an indication of ischemic stroke in 2005 on the basis of the results of a clinical trial with a unique dose of the drug (0.6 mg/kg). The Japan Stroke Society published the guidelines for intravenous application of rt-PA and organized training sessions for proper use all over Japan in an effort to promote the safe, widespread use of intravenous alteplase. Seven years following its approval, clinical experience with intravenous alteplase has accumulated, additional evidence of intravenous alteplase has been found in Japan and overseas, and the medical environment has substantially changed, including approvals for new drugs and medical devices. Notably, the use of alteplase in the extended therapeutic time window (within 4.5 hours of symptom onset) became covered by insurance in Japan in August 2012. To address these changing situations, we have decided to prepare the revised guidelines. In preparing the second edition, we took care to make its contents more practical by emphasizing information needed in clinical practice. While the first edition was developed with emphasis on safety in light of limited clinical experience with intravenous alteplase in Japan in 2005, this second edition is a substantial revision of the first edition mainly in terms of eligibility criteria, on the basis of accumulated evidence and the clinical experience.
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Affiliation(s)
- Kazuo Minematsu
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Liu X, Almast J, Ekholm S. Lesions masquerading as acute stroke. J Magn Reson Imaging 2013; 37:15-34. [PMID: 23255413 DOI: 10.1002/jmri.23647] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 02/21/2012] [Indexed: 11/11/2022] Open
Abstract
Rapid and accurate recognition of lesions masquerading as acute stroke is important. Any incorrect or delayed diagnosis of stroke mimics will not only increase the risk of being exposed to unnecessary and possibly dangerous interventional therapies, but will also delay proper treatment. In this article, written from a neuroradiologist's perspective, we classified these lesions masquerading as acute stroke into three groups: lesions that may have "normal imaging," lesions that are "symptom mimics" but on imaging clearly not a stroke, and lesions that are "symptom and imaging mimics" with imaging findings similar to stroke. We focused the review on neuroimaging findings of the latter two groups ending with a suggestion for a diagnostic approach in the form of an algorithm.
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Affiliation(s)
- Xiang Liu
- Division of Diagnostic & Interventional Neuroradiology, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York 14642-8638, USA
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Use of DWI-only MR protocol for screening stroke mimics. J Neurol Sci 2013; 328:37-40. [PMID: 23498367 DOI: 10.1016/j.jns.2013.02.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 02/09/2013] [Accepted: 02/14/2013] [Indexed: 11/21/2022]
Abstract
PURPOSE Patients presenting with focal neurological symptoms may suffer from stroke or stroke mimics. Diffusion weighted MRI (DWI) is highly sensitive for identifying acute ischemia. Therefore, we aimed to explore whether a DWI-only protocol would help differentiate stroke from stroke mimics. METHODS We identified all patients with possible but not definite stroke that underwent DWI-only MRI between 6/2010 and 8/2011. Patients with a positive DWI lesion were compared to those with negative DWI findings on demographics, risk factor profile, final discharge diagnoses, and outcome. RESULTS A total of 124 patients were included with a median age of 63.5 (53% male). DWI MRI was positive for acute ischemia in 46 patients (37%). The most frequent stroke mimics were peripheral vertigo (n=19), acute confusion (n=10), seizures (n=9) and migraine with aura (n=8). Most ischemic lesions were small on DWI (<2 cm) and patients had minor disability (mean NIHSS 4.9±3.9) with 81% of patients having good outcomes (modified Rankin Score≤2) at 3 months. On univariate analysis patients with positive DWI studies had higher frequencies of having more than one clinical symptom (56% vs. 13% respectively; P<0.001) and this variable remained a significant predictor for stroke on multivariate analysis (OR 9.4 95% CI 3.8-23.5). CONCLUSIONS A short DWI-only MRI protocol can effectively differentiate stroke from stroke mimics and could be used in settings of the emergency department as well as later on for diagnostic purposes. The chances for finding positive DWI lesions are increased in patients with multiple symptoms and signs.
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Zinkstok SM, Engelter ST, Gensicke H, Lyrer PA, Ringleb PA, Artto V, Putaala J, Haapaniemi E, Tatlisumak T, Chen Y, Leys D, Sarikaya H, Michel P, Odier C, Berrouschot J, Arnold M, Heldner MR, Zini A, Fioravanti V, Padjen V, Beslac-Bumbasirevic L, Pezzini A, Roos YB, Nederkoorn PJ. Safety of thrombolysis in stroke mimics: results from a multicenter cohort study. Stroke 2013; 44:1080-4. [PMID: 23444310 DOI: 10.1161/strokeaha.111.000126] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis for acute ischemic stroke is beneficial within 4.5 hours of symptom onset, but the effect rapidly decreases over time, necessitating quick diagnostic in-hospital work-up. Initial time strain occasionally results in treatment of patients with an alternate diagnosis (stroke mimics). We investigated whether intravenous thrombolysis is safe in these patients. METHODS In this multicenter observational cohort study containing 5581 consecutive patients treated with intravenous thrombolysis, we determined the frequency and the clinical characteristics of stroke mimics. For safety, we compared the symptomatic intracranial hemorrhage (European Cooperative Acute Stroke Study II [ECASS-II] definition) rate of stroke mimics with ischemic strokes. RESULTS One hundred stroke mimics were identified, resulting in a frequency of 1.8% (95% confidence interval, 1.5-2.2). Patients with a stroke mimic were younger, more often female, and had fewer risk factors except smoking and previous stroke or transient ischemic attack. The symptomatic intracranial hemorrhage rate in stroke mimics was 1.0% (95% confidence interval, 0.0-5.0) compared with 7.9% (95% confidence interval, 7.2-8.7) in ischemic strokes. CONCLUSIONS In experienced stroke centers, among patients treated with intravenous thrombolysis, only a few had a final diagnosis other than stroke. The complication rate in these stroke mimics was low.
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Affiliation(s)
- Sanne M Zinkstok
- Department of Neurology, Academic Medical Center University of Amsterdam, Amsterdam, the Netherlands
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Aseptic meningoencephalitis mimicking transient ischaemic attacks. Infection 2013; 41:485-91. [DOI: 10.1007/s15010-012-0397-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 12/22/2012] [Indexed: 11/26/2022]
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Sarikaya H, Yilmaz M, Luft AR, Gantenbein AR. Different Pattern of Clinical Deficits in Stroke Mimics Treated with Intravenous Thrombolysis. Eur Neurol 2012; 68:344-9. [DOI: 10.1159/000337677] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 02/14/2012] [Indexed: 11/19/2022]
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Pope JV, Edlow JA. Avoiding misdiagnosis in patients with neurological emergencies. Emerg Med Int 2012; 2012:949275. [PMID: 22888439 PMCID: PMC3410308 DOI: 10.1155/2012/949275] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 06/11/2012] [Indexed: 12/19/2022] Open
Abstract
Approximately 5% of patients presenting to emergency departments have neurological symptoms. The most common symptoms or diagnoses include headache, dizziness, back pain, weakness, and seizure disorder. Little is known about the actual misdiagnosis of these patients, which can have disastrous consequences for both the patients and the physicians. This paper reviews the existing literature about the misdiagnosis of neurological emergencies and analyzes the reason behind the misdiagnosis by specific presenting complaint. Our goal is to help emergency physicians and other providers reduce diagnostic error, understand how these errors are made, and improve patient care.
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Affiliation(s)
- Jennifer V. Pope
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) as an acute ischemic stroke mimic leading to systemic thrombolysis: A case report. Clin Neurol Neurosurg 2012; 114:689-90. [DOI: 10.1016/j.clineuro.2011.11.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 10/07/2011] [Accepted: 11/08/2011] [Indexed: 11/23/2022]
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How to identify stroke mimics in patients eligible for intravenous thrombolysis? J Neurol 2012; 259:1347-53. [DOI: 10.1007/s00415-011-6354-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 12/01/2011] [Accepted: 12/02/2011] [Indexed: 10/14/2022]
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Guillan M, Alonso-Canovas A, Gonzalez-Valcarcel J, Garcia Barragan N, Garcia Caldentey J, Hernandez-Medrano I, DeFelipe-Mimbrera A, Sanchez-Gonzalez V, Terecoasa E, Alonso de Leciñana M, Masjuan J. Stroke Mimics Treated with Thrombolysis: Further Evidence on Safety and Distinctive Clinical Features. Cerebrovasc Dis 2012; 34:115-20. [DOI: 10.1159/000339676] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 05/15/2012] [Indexed: 11/19/2022] Open
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Artto V, Putaala J, Strbian D, Meretoja A, Piironen K, Liebkind R, Silvennoinen H, Atula S, Häppölä O. Stroke mimics and intravenous thrombolysis. Ann Emerg Med 2011; 59:27-32. [PMID: 22000770 DOI: 10.1016/j.annemergmed.2011.09.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 09/09/2011] [Accepted: 09/13/2011] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE The necessity for rapid administration of intravenous thrombolysis in patients with acute ischemic stroke may lead to treatment of patients with conditions mimicking stroke. We analyze stroke patients treated with intravenous thrombolysis in our center to characterize cases classified as stroke mimics. METHODS We identified and reviewed all cases with a diagnosis other than ischemic stroke in our large-scale single-center stroke thrombolysis registry. We compared these stroke mimics with patients with neuroimaging-negative and neuroimaging-positive ischemic stroke results. RESULTS Among 985 consecutive intravenous thrombolysis-treated patients, we found 14 stroke mimics (1.4%; 95% confidence interval 0.8% to 2.4%), 694 (70.5%) patients with neuroimaging-positive ischemic stroke results, and 275 (27.9%) patients with neuroimaging-negative ischemic stroke results. Stroke mimics were younger than patients with neuroimaging-negative or -positive ischemic stroke results. Compared with patients with neuroimaging-positive ischemic stroke results, stroke mimics had less severe symptoms at baseline and better 3-month outcome. No differences appeared in medical history or clinical features between stroke mimics and patients with neuroimaging-negative ischemic stroke results. None of the stroke mimics developed symptomatic intracerebral hemorrhage compared with 63 (9.1%) among patients with neuroimaging-positive ischemic stroke results and 6 (2.2%) among patients with neuroimaging-negative ischemic stroke results. CONCLUSION Stroke mimics were infrequent among intravenous thrombolysis-treated stroke patients in this cohort, and their treatment did not lead to harmful complications.
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Affiliation(s)
- Ville Artto
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.
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Hansen JM, Schytz HW, Larsen VA, Iversen HK, Ashina M. Hemiplegic Migraine Aura Begins With Cerebral Hypoperfusion: Imaging in the Acute Phase. Headache 2011; 51:1289-96. [DOI: 10.1111/j.1526-4610.2011.01963.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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