Safety of thrombolysis in stroke mimics: an observational cohort study from an urban teaching hospital in Sweden

IV tPA for acute ischemic stroke in the setting of intracranial tumor: A scoping review

OBJECTIVE

A systematic review of published cases of standard-dose IV tPA for acute ischemic stroke (AIS) within 4.5 hours of symptom onset and intracranial tumor was performed.

MATERIALS AND METHODS

PubMed, Embase, and Cochrane were used to identify studies that included patients given standard-dose IV tPA for presumed AIS within 4.5 hours of symptom onset who had an intracranial tumor. The primary outcome measure was rate of ICH.

RESULTS

Twenty-three studies were included, involving 495 patient cases. One case-control study presented data only in the form of an odds ratio (OR), with OR 0.72 (p=0.16) for risk of ICH in 297 benign brain tumors, and OR for ICH of 2.33 (p value <0.001) in 119 malignant brain tumors, compared to controls. The remaining 22 sources included 79 cases; 49 were classified as benign, 16 malignant, and 14 "not otherwise specified." ICH occurred in 4; one was an asymptomatic parenchymal hematoma (5.1% total ICH, 3.8% symptomatic ICH). ICH only occurred in cases of malignant or metastatic intracranial tumors.

CONCLUSION

There were no reports of ICH in cases of benign intracranial tumor, and the reported rate of ICH with standard-dose IV tPA in the setting of any brain tumor appears similar to the general AIS population. There is heterogeneity and risk of selection bias with the included studies, and findings are not confirmatory. Further research is indicated to assess the rate of ICH with IV tPA for AIS in the setting of brain tumor.

Hypoglycemic hemiparesis as stroke mimic with transient splenial lesion and internal capsule involvement: A reversible clinico-radiological concurrence

Hypoglycemia presents with a spectrum of neurological manifestations ranging from lightheadedness to confusion and coma. We report here the case of a 61-year-old woman with right hemiparesis presenting within the window period for stroke thrombolysis. MRI brain showed diffusion restriction in posterior limb of left internal capsule and splenium. Patient had documented hypoglycemia of 38 mg/dL. Patient's hemiparesis resolved after glucose correction, and radiological findings completely resolved after 10 days. We present this case to highlight the rare radiological finding of simultaneous internal capsule and splenium involvement in hypoglycemic hemiparesis and the importance to rule out stroke mimics to avoid unwanted thrombolysis.

Mitochondrial Strokes: Diagnostic Challenges and Chameleons

Mitochondrial stroke-like episodes (SLEs) are a hallmark of mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS). They should be suspected in anyone with an acute/subacute onset of focal neurological symptoms at any age and are usually driven by seizures. Suggestive features of an underlying mitochondrial pathology include evolving MRI lesions, often originating within the posterior brain regions, the presence of multisystemic involvement, including diabetes, deafness, or cardiomyopathy, and a positive family history. The diagnosis of MELAS has important implications for those affected and their relatives, given it enables early initiation of appropriate treatment and genetic counselling. However, the diagnosis is frequently challenging, particularly during the acute phase of an event. We describe four cases of mitochondrial strokes to highlight the considerable overlap that exists with other neurological disorders, including viral and autoimmune encephalitis, ischemic stroke, and central nervous system (CNS) vasculitis, and discuss the clinical, laboratory, and imaging features that can help distinguish MELAS from these differential diagnoses.

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.

CE: Acute Ischemic Stroke

ABSTRACT

Stroke, the most common form of cerebrovascular disease, is a leading cause of death and disability throughout the world. There have been no significant advances in the development of effective therapeutics for hemorrhagic stroke, and for ischemic stroke highly effective, evidence-based therapies such as alteplase and mechanical thrombectomy are widely underutilized. Improving outcomes for patients experiencing ischemic stroke requires faster recognition and appropriate intervention within the treatment window (the first 24 hours after symptom onset). This article discusses the pathophysiology underlying the various types of ischemic stroke; the risk factors for ischemic stroke; stroke presentation; and the evidence-based treatments, nursing assessments, and monitoring protocols that are critical to patient recovery.

Functional neurological disorder in the emergency department

We provide a narrative review of functional neurological disorder (FND, or conversion disorder) for the emergency department (ED). Diagnosis of FND has shifted from a "rule-out" disorder to one now based on the recognition of positive clinical signs, allowing the ED physician to make a suspected or likely diagnosis of FND. PubMed, Google Scholar, academic books, and a hand search through review article references were used to conduct a literature review. We review clinical features and diagnostic pitfalls for the most common functional neurologic presentations to the ED, including functional limb weakness, functional (nonepileptic) seizures, and functional movement disorders. We provide practical advice for discussing FND as a possible diagnosis and suggestions for initial steps in workup and management plans.

Role of neuroimaging before reperfusion therapy. Part 1 - IV thrombolysis - Review

This review paper summarises the yield of the different imaging modalities in the evaluation of patients for IV thrombolysis. Non-contrast CT and CTA or brain MRI combined with MRA are the recommended sequences for the evaluation of patients within the 4.5 hours time window. Multimodal MRI (DWI/PWI), and more recently, CT perfusion, offer reliable surrogate of salvageable penumbra, the target mismatch, which is now currently used as selection criteria for revascularisation treatment in an extended time window. Those sequences may also help the physician for the management of other limited cases when the diagnosis of acute ischemic stroke is difficult. Another approach the DWI/FLAIR mismatch has been proposed to identify among wake-up stroke patients those who have been experiencing an acute ischemic stroke evolving from less than 4.5hrs. Other biomarkers, such as the clot imaging on MRI and CT, help to predict the recanalisation rate after IVT, while the impact of the presence microbleeds on MRI remains to be determined.

Ischemic stroke with a preceding Trans ischemic attack (TIA) less than 24 hours and thrombolytic therapy

Background

Acute ischemic stroke attack with and without a recent TIA may differ in clinical risk factors, and this may affect treatment outcomes following thrombolytic therapy. We examined whether the odds of exclusion or inclusion for thrombolytic therapy are greater in ischemic stroke with TIA less than 24 h preceding ischemic stroke (recent-TIA) as compared to those without recent TIA or non-TIA > 24 h and less than 1 month (past-TIA).

Methods

A retrospective hospital-based analysis was conducted on 6315 ischemic stroke patients, of whom 846 had proven brain diffusion-weighted magnetic resonance imaging (DW-MRI) of an antecedent TIA within 24 h prior to ischemic stroke. The logistic regression model was developed to generate odds ratios (OR) to determine clinical factors that may increase the likelihood of exclusion or inclusion for thrombolytic therapy. The validity of the model was tested using a Hosmer-Lemeshow test, while the Receiver Operating Curve (ROC) was used to test the sensitivity of our model.

Results

In the recent-TIA ischemic stroke population, patients with a history of alcohol abuse (OR = 5.525, 95% CI, 1.003–30.434, p = 0.05), migraine (OR = 4.277, 95% CI, 1.095–16.703, p = 0.037), and increasing NIHSS score (OR = 1.156, 95% CI, 1.058–1.263, p = 0.001) were associated with the increasing odds of receiving rtPA, while older patients (OR = 0.965, 95% CI, 0.934–0.997, P = 0.033) were associated with the increasing odds of not receiving rtPA.

Conclusion

In recent-TIA ischemic stroke patients, older patients with higher INR values are associated with increasing odds of exclusion from thrombolytic therapy. Our findings demonstrate clinical risks factors that can be targeted to improve the use and eligibility for rtPA in in recent-TIA ischemic stroke patients.

Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials

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.

Alcohol Intoxication as a Stroke Mimic and the Incidence of Acute Alcohol Intoxication in Stroke

BACKGROUND AND AIM

Alcohol intoxication can be a posterior circulation stroke mimic as they share symptoms such as dysarthria, gait disturbances and nystagmus. We describe alcohol intoxication as a stroke mimic and the frequency of acute alcohol intoxication among stroke patients.

METHODS

Prospective observational single-center study (2014-2017, Haga Ziekenhuis, the Hague). In all patients older than 16 years presenting as possible acute stroke less than 6 hours of onset, blood ethanol was measured; greater than 0.1 blood alcohol concentration (BAC) was considered elevated.

RESULTS

In total 974 patients were included: 60 (6%) had elevated blood ethanol (mean: 1.3 BAC). In 180 of 974 patients (18%) a stroke mimic was diagnosed: 12 were due to alcohol intoxication (1% of total cohort, 7% of stroke mimic, mean ethanol level: 2.2 BAC). Half of these patients denied or downplayed their alcohol consumption. Stroke and concurrent alcohol intoxication occurred in 38 of 794 strokes (5%, mean ethanol level: 1.1 BAC). Compared to other stroke patients, these 38 patients presented more often after working hours (mean 6.38pm versus 2.23pm) and received alteplase and endovascular therapy less often (24% versus 43%, P = .018 and 3% versus 10%, P = .241, respectively).

CONCLUSIONS

Of all patients presenting as possible acute stroke, 6% also drank alcohol. 18% of the whole cohort was diagnosed with a stroke mimic. Acute alcohol intoxication as sole diagnosis was diagnosed in 1% of the total cohort and 7% of stroke mimics, 50% denied or downplayed their alcohol consumption. 5% of all stroke patients also drank alcohol, they were significantly less likely to receive alteplase or endovascular treatment.

CT-guided thrombolytic treatment of patients with wake-up strokes

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.

Epilepsy after stroke: Definitions, problems and a practical approach for clinicians

Stroke, whether ischemic or hemorrhagic, is the main etiology of epilepsy in the elderly. However, incidences and outcomes differ according to stroke subtype and delay of onset following the stroke. While the medical literature is extensive, it is not always consistent, and many questions still remain regarding risk factors and management of vascular epilepsy. Thus, the present report here is an overview of the clinical aspects of vascular epilepsy using a practical approach that integrates data from meta-analyses and the more recently published expert recommendations.