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Nguyen L, Lee JH, Ganti L, Rivera-Morales M, Dub L. Intravenous Thrombolysis for a Stroke Mimic Patient. Case Rep Neurol 2021; 13:704-709. [PMID: 34899256 PMCID: PMC8613626 DOI: 10.1159/000519764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/15/2021] [Indexed: 11/19/2022] Open
Abstract
The authors present the case of a young woman on phentermine and herbal supplements who presented as an acute stroke alert with right-sided facial droop and numbness. She was treated acutely with intravenous tissue plasminogen activator (tPA). However, the workup did not reveal any evidence of cerebrovascular disease or cerebral infarct. The authors discuss plausible stroke mimics and the safety of administering tPA to such patients.
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Affiliation(s)
- Lilly Nguyen
- Trinity Preparatory School, Winter Park, Florida, USA
| | - Joyce Hoonsuh Lee
- Department of Biology, Brown University, Providence, Rhode Island, USA
| | - Latha Ganti
- Department of Emergency Medicine, University of Central Florida, Jacksonville, Florida, USA.,Envision Physician Services, Plantation, Florida, USA.,HCA Healthcare, Nashville, Tennessee, USA
| | - Mark Rivera-Morales
- Department of Emergency Medicine, University of Central Florida, Jacksonville, Florida, USA.,Envision Physician Services, Plantation, Florida, USA
| | - Larissa Dub
- Department of Emergency Medicine, University of Central Florida, Jacksonville, Florida, USA.,Envision Physician Services, Plantation, Florida, USA.,HCA Healthcare, Nashville, Tennessee, USA
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Kargiotis O, Oikonomi K, Geka A, Psychogios K, Safouris A, Zis P, Kararizou E, Papadionisiou P, Tsivgoulis G. HSV-Encephalitis Resembling Acute Cerebral Infarction in a Patient With Atrial Fibrillation: Beware of Stroke Mimics. Neurologist 2021; 27:30-33. [PMID: 34842570 DOI: 10.1097/nrl.0000000000000353] [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: 11/26/2022]
Abstract
INTRODUCTION Herpes simplex virus-1 (HSV-1) encephalitis, the most common and potentially life-threatening type of encephalitis, may rarely present as a stroke mimic. Prompt diagnosis is of paramount importance for the timely initiation of antiviral treatment and to avert intravenous thrombolysis. CASE REPORT A 60-year-old man with a history of lone paroxysmal atrial fibrillation without prior antithrombotic treatment was admitted due to mild gait unsteadiness and intermittent dysarthria of acute onset. On admission, the patient was afebrile, whereas neurological examination revealed only a mild pronator drift on the left. Brain magnetic resonance imaging (MRI) showed an extensive right temporo-occipital and thalamic lesion with restricted diffusion and 3 small-sized hemorrhagic foci. Brain MR-angiography did not show large vessel stenosis or occlusion. On the basis of careful observation and the depiction of several imaging discrepancies, such as early vasogenic edema and hemorrhagic transformation, as well as uncus involvement, but also the lack of significant neurological deficits despite the size of the brain lesion we suspected viral encephalitis which was confirmed by the detection of HSV-1 DNA in the cerebrospinal fluid. CONCLUSION HSV-encephalitis might occasionally result in the development of unilateral brain MRI lesions with extensive cytotoxic edema, resembling an acute ischemic stroke. Therefore, HSV-encephalitis must be considered in the differential diagnosis of acute ischemic stroke with atypical presentation. The presence of a significant dissociation between the brain MRI lesion volume and the neurological deficits, as well as certain brain MRI imaging discrepancies might serve as "red flags" to extend the diagnostic workup.
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Affiliation(s)
| | | | | | | | | | | | - Evangelia Kararizou
- First Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, National & Kapodistiran University of Athens, "Attikon" University Hospital, Athens, Greece
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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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Headache in Children: Selected Factors of Vascular Changes Involved in Underlying Processes of Idiopathic Headaches. CHILDREN-BASEL 2020; 7:children7100167. [PMID: 33020432 PMCID: PMC7600888 DOI: 10.3390/children7100167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 11/16/2022]
Abstract
Headaches are common complaints in children. The International Classification of Headache Disorders, 3rd edition (beta version), defines more than 280 types of headaches. Primary headaches refer to independent conditions that cause pain and include migraine, tension-type headaches (TTH), and trigeminal autonomic cephalalgias (TACs). Several agents are involved in the pathogenesis of headaches. The factors associated with predisposition to atherosclerosis seem to be particularly important from the clinical point of view. The influence of obesity on the incidence of headaches has been well established. Moreover, idiopathic headaches, especially migraine, are thought to be one of the first signs of disorders in lipid metabolism and atherosclerosis. The risk of migraine increases with increasing obesity in children. Another factor that seems to be involved in both obesity and headaches is the adiponectin level. Recent data also suggest new potential risk factors for atherosclerosis and platelet aggregation such as brain-derived neurotrophic factor (BDNF), sCD40L (soluble CD40 ligand), serpin E1/PAI I (endothelial plasminogen activator inhibitor), and vascular endothelial growth factor (VEGF). However, their role is controversial because the results of clinical studies are often inconsistent. This review presents the current knowledge on the potential markers of atherosclerosis and platelet aggregation, which may be associated with primary headaches.
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Machner B, Choi JH, Neumann A, Trillenberg P, Helmchen C. What guides decision-making on intravenous thrombolysis in acute vestibular syndrome and suspected ischemic stroke in the posterior circulation? J Neurol 2020; 268:249-264. [PMID: 32772173 PMCID: PMC7815559 DOI: 10.1007/s00415-020-10134-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 11/28/2022]
Abstract
Intravenous thrombolysis (IVT) is rarely performed in dizzy patients with acute vestibular syndrome (AVS) or acute imbalance (AIS) even if posterior circulation stroke (PCS) is suspected. Decision-making may be affected by uncertainties in discriminating central from peripheral vestibulopathy or concerns of IVT-related harm, particularly intracerebral hemorrhage (ICH), but related studies are missing. Using an in-house register of dizzy patients coming to the emergency room, we identified 29 AVS/AIS patients who presented within 4.5 h after onset, revealed clinical signs indicative of PCS (central oculomotor signs, mild focal abnormalities), and had non-contrast computed tomography (NCCT). Patients treated with IVT (n = 15) were compared to NoIVT patients (n = 14) with regard to clinical and imaging (including perfusion computed tomography, CTP) parameters, occurrence of ICH and short-term clinical outcome (NIHSS improvement; ability to walk independently). IVT and NoIVT patients did not differ in baseline characteristics, central oculomotor signs, or clinical outcome. IVT patients more often exhibited disabling vestibular symptoms (severe dizziness/vertigo, inability to stand unsupported) and focal abnormalities than NoIVT patients. There was no ICH in either group. CTP was performed in 0% of NoIVT versus 80% of IVT patients, seven of twelve revealing posterior circulation hypoperfusion. Comparison of initial hypoperfusion (CTP) and final stroke (NCCT) revealed IVT-related benefit (smaller lesion) in three of seven IVT patients. In AVS/AIS patients with suspected PCS, disabling vestibular symptoms, focal neurological deficits, and hypoperfusion on CTP seem to direct decision-making pro IVT. In our small cohort, there were no significant IVT-related clinical benefits, no IVT-related ICHs, and salvage of brain tissue in some patients.
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Affiliation(s)
- Björn Machner
- Department of Neurology, University Hospitals Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Jin Hee Choi
- Department of Neurology, University Hospitals Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Alexander Neumann
- Department of Neuroradiology, University Hospitals Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Peter Trillenberg
- Department of Neurology, University Hospitals Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Christoph Helmchen
- Department of Neurology, University Hospitals Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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Wijerathne H, Witek MA, Baird AE, Soper SA. Liquid biopsy markers for stroke diagnosis. Expert Rev Mol Diagn 2020; 20:771-788. [PMID: 32500751 PMCID: PMC8157911 DOI: 10.1080/14737159.2020.1777859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/01/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION There is a short time window (4.5 h) for the effective treatment of acute ischemic stroke (AIS), which uses recombinant tissue plasminogen activator (rt-PA). Unfortunately, this short therapeutic timeframe is a contributing factor to the relatively small number of patients (~7%) that receive rt-PA. While neuroimaging is the major diagnostic for AIS, more timely decisions could be made using a molecular diagnostic. AREAS COVERED In this review, we survey neuroimaging techniques used to diagnose stroke and their limitations. We also highlight the potential of various molecular/cellular biomarkers, especially peripheral blood-based (i.e. liquid biopsy) biomarkers, for diagnosing stroke to allow for precision decisions on managing stroke in a timely manner. Both protein and nucleic acid molecular biomarkers are reviewed. In particular, mRNA markers are discussed for AIS and hemorrhagic stroke diagnosis sourced from both cells and extracellular vesicles. EXPERT OPINION While there are a plethora of molecular markers for stroke diagnosis that have been reported, they have yet to be FDA-cleared. Possible reasons include the inability for these markers to appear in sufficient quantities for highly sensitive clinical decisions within the rt-PA therapeutic time.
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Affiliation(s)
- Harshani Wijerathne
- Department of Chemistry, The University of Kansas, Lawrence, KS, USA
- Center of BioModular Multiscale Systems for Precision Medicine, The University of Kansas, Lawrence, KS, USA
| | - Malgorzata A. Witek
- Department of Chemistry, The University of Kansas, Lawrence, KS, USA
- Center of BioModular Multiscale Systems for Precision Medicine, The University of Kansas, Lawrence, KS, USA
- Department of Cancer Biology and KU Cancer Center, University of Kansas Medical Center, Cancer Center, Kansas City, KS, USA
| | - Alison E. Baird
- Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Steven A. Soper
- Department of Chemistry, The University of Kansas, Lawrence, KS, USA
- Center of BioModular Multiscale Systems for Precision Medicine, The University of Kansas, Lawrence, KS, USA
- Department of Cancer Biology and KU Cancer Center, University of Kansas Medical Center, Cancer Center, Kansas City, KS, USA
- Bio Engineering Program, The University of Kansas, Lawrence, KS, USA
- Department of Mechanical Engineering, The University of Kansas, Lawrence, KS, USA
- Biofluidica, Inc, San Diego, CA, USA
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Raut S, Singh U, Sarmah D, Datta A, Baidya F, Shah B, Bohra M, Jagtap P, Sarkar A, Kalia K, Borah A, Dave KR, Yavagal DR, Bhattacharya P. Migraine and Ischemic Stroke: Deciphering the Bidirectional Pathway. ACS Chem Neurosci 2020; 11:1525-1538. [PMID: 32348103 DOI: 10.1021/acschemneuro.0c00137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Migraine and stroke are common, disabling neurological conditions with several theories being proposed to explain this bidirectional relationship. Migraine is considered as a benign neurological disorder, but research has revealed a connection between migraine and stroke, predominantly those having migraine with aura (MA). Among migraineurs, females with MA are more susceptible to ischemic stroke and may have a migrainous infarction. Migrainous infarction mostly occurs in the posterior circulation of young women. Although there are several theories about the potential relationship between MA and stroke, the precise pathological process of migrainous infarction is not clear. It is assumed that cortical spreading depression (CSD) might be one of the essential factors for migrainous infarction. Other factors that may contribute to migrainous infarction may be genetic, hormonal fluctuation, hypercoagulation, and right to left cardiac shunts. Antimigraine drugs, such as ergot alkaloids and triptans, are widely used in migraine care. Still, they have been found to cause severe vasoconstriction, which may result in the development of ischemia. It is reported that patients with stroke develop migraines during the recovery phase. Both experimental and clinical data suggest that cerebral microembolism can act as a potential trigger for MA. Further studies are warranted for the treatment of migraine, which may lead to a decline in migraine-related stroke. In this present article, we have outlined various potential pathways that link migraine and stroke.
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Affiliation(s)
- Swapnil Raut
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Upasna Singh
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Deepaneeta Sarmah
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Aishika Datta
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Falguni Baidya
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Birva Shah
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Mariya Bohra
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Priya Jagtap
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Ankan Sarkar
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Kiran Kalia
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Anupom Borah
- Cellular and Molecular Neurobiology Laboratory, Department of Life Science and Bioinformatics, Assam University, Silchar, Assam 788011, India
| | - Kunjan R. Dave
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida 33136, United States
| | - Dileep R. Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida 33136, United States
| | - Pallab Bhattacharya
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
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Willenberg R, Leung B, Song S, Dumitrascu OM, Schlick K, Lyden P. Munchausen Syndrome by Tissue Plasminogen Activator: Patients Seeking Thrombolytic Administration. Neurol Clin Pract 2020; 11:64-68. [PMID: 33968474 DOI: 10.1212/cpj.0000000000000828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/26/2020] [Indexed: 11/15/2022]
Abstract
Purpose of Review Munchausen syndrome by tissue plasminogen activator (tPA) is a phenomenon we describe as patients exhibiting factitious symptoms to assume the role of the sick patient, desiring and received tPA, with no alternative diagnosis or secondary gain to better account for their presentation. To illustrate this phenomenon and its magnitude, we present a series of cases of Munchausen syndrome by tPA, prevalence in our stroke center, and highlight one illustrative case. Recent Findings Of 335 cases with tPA administration over 29 months, 10 were confirmed as Munchausen syndrome by tPA, reflecting a 3.0% prevalence in our stroke center. Summary Munchausen syndrome by tPA is an underappreciated phenomenon encountered in evaluating patients with acute stroke symptoms. Administering tPA in Munchausen syndrome poses an ethical dilemma because standard of care favors rapid tPA administration, but administration can cause harm, burdens the healthcare system, and does not treat the patient's Munchausen syndrome.
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Affiliation(s)
- Rafer Willenberg
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Bo Leung
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Shlee Song
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Oana M Dumitrascu
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Konrad Schlick
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Patrick Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
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CT perfusion and EEG patterns in patients with acute isolated aphasia in seizure-related stroke mimics. Seizure 2019; 71:110-115. [DOI: 10.1016/j.seizure.2019.07.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 11/22/2022] Open
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10
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Garg R, Rech MA, Schneck M. Stroke Mimics: An Important Source of Bias in Acute Ischemic Stroke Research. J Stroke Cerebrovasc Dis 2019; 28:2475-2480. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/05/2019] [Accepted: 06/15/2019] [Indexed: 01/22/2023] Open
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Polverino P, Caruso P, Ridolfi M, Furlanis G, Naccarato M, Sartori A, Manganotti P. Acute isolated aphasia as a challenging symptom in the emergency setting: Predictors of epileptic mimic versus ischemic stroke. J Clin Neurosci 2019; 67:129-133. [DOI: 10.1016/j.jocn.2019.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
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12
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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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Ischemic Stroke in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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14
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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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Abstract
Stroke is the clinical syndrome of acute onset of neurologic deficit caused by ischemia or hemorrhage. Neuroimaging has a crucial role in differentiating ischemic from hemorrhagic stroke. Advanced neuroimaging has become essential in the management of patients with acute ischemic stroke mainly because of improved awareness of the imaging findings and their role in patient selection for novel treatment options as highlighted in recent clinical trials, including "late window" (8-24 hours post ictus!) intra-arterial thrombectomy. This article focuses on the role of neuroimaging in the management of patients with acute ischemic stroke.
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Affiliation(s)
- Shahmir Kamalian
- Department of Radiology, Division of Emergency Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Blake SB Room 29A, Boston, MA 02114, USA.
| | - Michael H Lev
- Department of Radiology, Division of Emergency Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Blake SB Room 29A, Boston, MA 02114, USA
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16
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Catangui EJ. Identifying and differentiating stroke and stroke mimics. Nurs Stand 2019; 34:e11110. [PMID: 31468889 DOI: 10.7748/ns.2019.e11110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 11/09/2022]
Abstract
Stroke mimics are common differential diagnoses of stroke. This article describes common stroke mimics and their presentations. It provides nurses with an overview of how to distinguish stroke mimics from a stroke, and practical information on triaging and diagnosing stroke and stroke mimics in the clinical setting. Stroke and stroke mimics have several similarities and several important differences. A comprehensive patient history, clinical examination, use of assessment tools and the results of medical imaging can guide nurses to differentiate stroke from a stroke mimic.
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Sordyl J, Kopyta I, Sarecka-Hujar B, Francuz T, Matusik P, Małecka-Tendera E. Lipid levels and selected biomarkers of vascular changes in children with idiopathic headaches - a preliminary report. Arch Med Sci 2019; 15:120-125. [PMID: 30697261 PMCID: PMC6348343 DOI: 10.5114/aoms.2018.73983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 01/07/2018] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Elevated lipid concentrations were observed in adults with headaches. However, studies in children are scarce. Recent data suggest new potential risk factors for atherosclerosis, which may be associated with headaches. The aim of the study was to analyse the blood levels of lipids and new markers of atherosclerosis in children with idiopathic headaches. MATERIAL AND METHODS The study population comprised 65 children (39 with idiopathic headaches and 26 healthy children). Total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL) cholesterol and triacylglycerol (TG) levels were measured in every patient. Brain-derived neurotrophic factor (BDNF), soluble CD40 ligand (sCD40L), endothelial plasminogen activator inhibitor (serpin E1/PAI I) and vascular endothelial growth factor (VEGF) blood level measurements were performed in 34 children. RESULTS Children with headaches had higher BMI z-scores (0.2 vs. -1.14; p = 0.006). TC level was lower in patients with headaches (121.04 mg/dl vs. 146.87 mg/dl, p = 0.019). No differences in concentrations of TG, HDL or LDL were found. BDNF was significantly higher in the studied group (171.57 pg/ml vs. 64.04 pg/ml, p = 0.012). The VEGF was higher in boys with headaches than in girls (368.27 pg/ml vs. 142.86 pg/ml, p = 0.011). There were no differences in levels of VEGF, sCD40L or PAI-1 between groups. CONCLUSIONS Children with headaches have lower total cholesterol and higher BDNF levels than controls. No significant difference in levels of triacylglycerols, HDL cholesterol, LDL cholesterol, VEGF, sCD40L or PAI-1 was found between children with headaches and controls.
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Affiliation(s)
- Joanna Sordyl
- Department of Paediatrics and Paediatric Endocrinology, School of Medicine, Medical University of Silesia, Katowice, Poland
| | - Ilona Kopyta
- Department of Paediatric Neurology, School of Medicine, Medical University of Silesia, Katowice, Poland
| | - Beata Sarecka-Hujar
- Department of Pharmaceutical Technology, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, Poland
| | - Tomasz Francuz
- Department of Biochemistry, School of Medicine, Medical University of Silesia, Katowice, Poland
| | - Paweł Matusik
- Department of Paediatrics and Paediatric Endocrinology, School of Medicine, Medical University of Silesia, Katowice, Poland
| | - Ewa Małecka-Tendera
- Department of Paediatrics and Paediatric Endocrinology, School of Medicine, Medical University of Silesia, Katowice, Poland
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18
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Colella M, Strada L, Bianchini D, Ajmar G, Del Sette M. Stroke or Stramonium? A novel stroke mimic. Neurol Sci 2018; 40:631-632. [PMID: 30341480 DOI: 10.1007/s10072-018-3609-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/15/2018] [Indexed: 10/28/2022]
Affiliation(s)
- M Colella
- Neurology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy.,IRCCS Neurolesi Bonino-Pulejo-Ospedale Piemonte, Messina, Italy
| | - L Strada
- Neurology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy
| | - D Bianchini
- Neurology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy
| | - G Ajmar
- Neurology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy
| | - M Del Sette
- Neurology Unit, Ente Ospedaliero Ospedali Galliera, Genoa, Italy.
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19
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Van Cauwenberge MG, Dekeyzer S, Nikoubashman O, Dafotakis M, Wiesmann M. Can perfusion CT unmask postictal stroke mimics? Neurology 2018; 91:e1918-e1927. [DOI: 10.1212/wnl.0000000000006501] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 08/03/2018] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo study the diagnostic value of volume perfusion CT (VPCT) in patients with transient focal neurologic deficits following and during epileptic seizures, that mimic symptoms of stroke.MethodsA retrospective case-control study was performed on 159 patients who presented with a seizure and received an emergency VPCT within the first 3.5 hours of admission, after being misjudged to have an acute stroke. The reference test was a clinical-based, EEG-supported diagnostic algorithm for seizure.ResultsWe included 133 patients: 94 stroke-mimicking cases with postictal focal neurologic deficits (“Todd phenomenon,” n = 67) or ongoing seizure on hospital admission (“ictal patients,” n = 27), and 39 postictal controls without focal neurologic deficits. Patients with Todd phenomenon showed normal perfusion (64%), hypoperfusion (21%), and hyperperfusion (14%) on early VPCT. Ictal patients displayed more hyperperfusion compared to postictal patients (p = 0.015). Test sensitivity of hyperperfusion for ictal patients is 38% (95% confidence interval [CI] 20.7%–57.7%), specificity 86% (95% CI 77.3%–91.7%), positive predictive value is 42% (95% CI 27.5%–58.7%), and the negative predictive value 83% (95% CI 78.6%–86.9%). A cortical distribution was seen in all hyperperfusion scans, compared to a cortico-subcortical pattern in hypoperfusion (p < 0.001). A history of complex focal seizure and age were associated with hyperperfusion (p = 0.046 and 0.038, respectively).ConclusionVPCT can differentiate ictal stroke mimics with hyperperfusion from acute ischemic stroke, but not postictal patients who display perfusion patterns overlapping with ischemic stroke.Classification of evidenceThis study provides Class IV evidence that VPCT accurately differentiates ictal stroke mimics from acute ischemic stroke.
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20
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Geisler F, Ali SF, Ebinger M, Kunz A, Rozanski M, Waldschmidt C, Weber JE, Wendt M, Winter B, Schwamm LH, Audebert HJ. Evaluation of a score for the prehospital distinction between cerebrovascular disease and stroke mimic patients. Int J Stroke 2018; 14:400-408. [DOI: 10.1177/1747493018806194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Patients with a sudden onset of focal neurological deficits consistent with stroke, who turn out to have alternative conditions, have been labeled stroke mimics. Aims We assessed a recently validated telemedicine-based stroke mimic score (TeleStroke mimic score; TM-score) and individual patient characteristics with regard to its discriminative value between cerebrovascular disease and stroke mimic patients in the in-person, pre-hospital setting. Methods We evaluated patients cared for in a mobile stroke unit in Berlin, Germany. We investigated whether the TM-score (comprising six parameters), Face Arm Speech Time test, and individual patient characteristics were able to differentiate cerebrovascular disease from stroke mimic patients. Results We included 423 patients (299 (70.7%) cerebrovascular disease and 124 (29.3%) stroke mimic) in the final analysis. A TM-score > 30 indicated a high probability of a cerebrovascular disease and a score ≤15 of a stroke mimic. The TM-score performed well to identify stroke mimics (area under the curve of 0.74 under receiver-operating characteristic curve analysis). The cerebrovascular disease patients were older (74.8 vs. 69.8 years, p = 0.001), had more often severe strokes (NIHSS > 14 25.8% vs. 11.3%, p = 0.001), presented more often with weakness of the face (70.9% vs. 42.7%, p = 0.001) or arm (60.9% vs. 33.9%, p = 0.001), dysarthria (59.5% vs. 40.3%, p < 0.001), history of atrial fibrillation (38.1% vs. 21.0%, p = 0.001), arterial hypertension (78.9% vs. 53.2%, p < 0.001), and less often with seizure (0.7% vs. 21.0%, p < 0.001). Conclusions The TM-score and certain patient characteristics can help paramedics and emergency physicians in the field to identify stroke mimic patients and select the most appropriate hospital destination.
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Affiliation(s)
- Frederik Geisler
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Syed F Ali
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Martin Ebinger
- Department of Neurology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Alexander Kunz
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Michal Rozanski
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Carolin Waldschmidt
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim E Weber
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Wendt
- Department of Neurology, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Benjamin Winter
- Department of Neurology, St. Josefs-Krankenhaus, Potsdam-Sanssouci, Germany
| | - Lee H Schwamm
- Department of Neurology, MGH Stroke Services, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Heinrich J Audebert
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
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21
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Willems LM, Kurka N, Bohmann F, Rostek P, Pfeilschifter W. Tools for your stroke team: adapting crew-resource management for acute stroke care. Pract Neurol 2018; 19:36-42. [PMID: 30097552 DOI: 10.1136/practneurol-2018-001966] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2018] [Indexed: 11/04/2022]
Abstract
Crew-resource management is an approach to work and training that focuses on non-technical skills and strategies to prevent human error in complex procedures. It was initially termed 'cockpit-resource management' and developed for aviation in the 1970s after several severe accidents; it has contributed to a measurable increase in flight safety. In recent years, this approach has been successfully implemented in other high-reliability environments; surgical disciplines have made particular use of crew-resource management strategies and training, with resulting reduced mortality rates. The stepwise implementation of different crew-resource management strategies in stroke care at our tertiary stroke centre has helped to speed up process times significantly, and to improve patient safety and staff satisfaction. Here, we summarise our experience in adapting different crew-resource management tools to acute stroke care, sharing specific tools that have proven valuable in our hands, and we encourage colleagues to implement such strategies in acute stroke care.
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Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Goethe-University, Frankfurt am Main, Germany.,Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Natalia Kurka
- Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Ferdinand Bohmann
- Department of Neurology, Goethe-University, Frankfurt am Main, Germany
| | - Peter Rostek
- Department of Neurology, Goethe-University, Frankfurt am Main, Germany
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22
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Kvistad CE, Novotny V, Næss H, Hagberg G, Ihle-Hansen H, Waje-Andreassen U, Thomassen L, Logallo N. Safety and predictors of stroke mimics in The Norwegian Tenecteplase Stroke Trial (NOR-TEST). Int J Stroke 2018; 14:508-516. [DOI: 10.1177/1747493018790015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Stroke mimics are frequently treated with thrombolysis in clinical practice and thrombolytic trials. Although alteplase in stroke mimics has proven to be safe, safety of tenecteplase in stroke mimics has not been assessed in an ischemic stroke study setting. We aimed to assess clinical characteristics and safety of stroke mimics treated with thrombolysis in the Norwegian Tenecteplase Stroke Trial. We also aimed to identify possible predictors of stroke mimics as compared to patients with acute cerebral ischemia. Methods Norwegian Tenecteplase Stroke Trial was a phase-3 trial investigating safety and efficacy of tenecteplase vs. alteplase in patients with suspected acute cerebral ischemia. Two groups were defined based on diagnose at discharge: patients with a different diagnose than ischemic stroke or transient ischemic attack (stroke mimics group) and patients diagnosed with ischemic stroke or transient ischemic attack (acute cerebral ischemia group). Logistic regression analyses were performed with stroke mimics vs. acute cerebral ischemia as dependent variable to identify predictors of stroke mimics. Results Of 1091 randomized patients, 181 (16.6%) were stroke mimics. Migraine (22.2%) and peripheral vertigo (11.4%) were the two most frequent stroke mimic-diagnoses. There was no symptomatic intracerebral hemorrhage in the stroke mimics group. Stroke mimics were independently associated with age ≤60 years (OR 2.75, p < 0.001), female sex (OR 1.48, p = 0.026), no history of myocardial infarction (OR 2.03, p = 0.045), systolic BP ≤ 150 mmHg (OR 2.33, p < 0.001), NIHSS ≤ 6 points (OR 1.83, p = 0.011), sensory loss (OR 1.55, p = 0.015), and no facial paresis (OR 2.41, p < 0.001) on admission. Conclusion Thrombolysis with tenecteplase seems to be as safe as with alteplase in stroke mimics. Predictors were identified for stroke mimics which may contribute to differentiate stroke mimics from acute cerebral ischemia in future stroke trials.
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Affiliation(s)
- Christopher Elnan Kvistad
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Vojtech Novotny
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Halvor Næss
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Guri Hagberg
- Department of Medicine, Vestre Viken HT, Bærum Hospital, Drammen, Norway
| | - Hege Ihle-Hansen
- Department of Medicine, Vestre Viken HT, Bærum Hospital, Drammen, Norway
| | - Ulrike Waje-Andreassen
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Thomassen
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Nicola Logallo
- Center for Neurovascular Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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Kamalian S, Lev MH. The Adult Patient with Acute Neurologic Deficit: An Update on Imaging Trends. Neuroimaging Clin N Am 2018; 28:319-334. [PMID: 30007748 DOI: 10.1016/j.nic.2018.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Stroke is the clinical syndrome of abrupt onset of acute neurologic deficit owing to decreased oxygen delivery to the brain, resulting in ischemia or infarction. Approximately 87% of strokes are ischemic and 13% are hemorrhagic. Improved awareness of the neuroimaging findings highlighted in recent stroke clinical trials, as well as of their role in patient selection for novel treatment options-including "late window" (8-24 hours post-ictus!) intraarterial thrombectomy-has become increasingly important. This article focuses on the role of neuroimaging in the assessment and management of patients with acute ischemic stroke.
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Affiliation(s)
- Shahmir Kamalian
- Division of Emergency Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Blake SB Room 29A, Boston, MA 02114, USA.
| | - Michael H Lev
- Division of Emergency Radiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Blake SB Room 29A, Boston, MA 02114, USA
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24
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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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25
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Ali SF, Hubert GJ, Switzer JA, Majersik JJ, Backhaus R, Shepard LW, Vedala K, Schwamm LH. Validating the TeleStroke Mimic Score: A Prediction Rule for Identifying Stroke Mimics Evaluated Over Telestroke Networks. Stroke 2018; 49:688-692. [PMID: 29374105 DOI: 10.1161/strokeaha.117.018758] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 11/28/2017] [Accepted: 12/07/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Up to 30% of acute stroke evaluations are deemed stroke mimics, and these are common in telestroke as well. We recently published a risk prediction score for use during telestroke encounters to differentiate stroke mimics from ischemic cerebrovascular disease derived and validated in the Partners TeleStroke Network. Using data from 3 distinct US and European telestroke networks, we sought to externally validate the TeleStroke Mimic (TM) score in a broader population. METHODS We evaluated the TM score in 1930 telestroke consults from the University of Utah, Georgia Regents University, and the German TeleMedical Project for Integrative Stroke Care Network. We report the area under the curve in receiver-operating characteristic curve analysis with 95% confidence interval for our previously derived TM score in which lower TM scores correspond with a higher likelihood of being a stroke mimic. RESULTS Based on final diagnosis at the end of the telestroke consultation, there were 630 of 1930 (32.6%) stroke mimics in the external validation cohort. All 6 variables included in the score were significantly different between patients with ischemic cerebrovascular disease versus stroke mimics. The TM score performed well (area under curve, 0.72; 95% confidence interval, 0.70-0.73; P<0.001), similar to our prior external validation in the Partners National Telestroke Network. CONCLUSIONS The TM score's ability to predict the presence of a stroke mimic during telestroke consultation in these diverse cohorts was similar to its performance in our original cohort. Predictive decision-support tools like the TM score may help highlight key clinical differences between mimics and patients with stroke during complex, time-critical telestroke evaluations.
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Affiliation(s)
- Syed F Ali
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.F.A., L.H.S.); Department of Neurology and Neurological Intensive Care, Staedtisches Klinikum München, TeleMedical Project for integrative Stroke Care, Munich, Germany (G.J.H.); Department of Neurology, Augusta University, GA (J.S., K.V.); Division of Vascular Neurology, University of Utah, Salt Lake City (J.J.M., L.W.S.); and Department of Neurology, University Regensburg, Germany (R.B.)
| | - Gordian J Hubert
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.F.A., L.H.S.); Department of Neurology and Neurological Intensive Care, Staedtisches Klinikum München, TeleMedical Project for integrative Stroke Care, Munich, Germany (G.J.H.); Department of Neurology, Augusta University, GA (J.S., K.V.); Division of Vascular Neurology, University of Utah, Salt Lake City (J.J.M., L.W.S.); and Department of Neurology, University Regensburg, Germany (R.B.)
| | - Jeffrey A Switzer
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.F.A., L.H.S.); Department of Neurology and Neurological Intensive Care, Staedtisches Klinikum München, TeleMedical Project for integrative Stroke Care, Munich, Germany (G.J.H.); Department of Neurology, Augusta University, GA (J.S., K.V.); Division of Vascular Neurology, University of Utah, Salt Lake City (J.J.M., L.W.S.); and Department of Neurology, University Regensburg, Germany (R.B.)
| | - Jennifer J Majersik
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.F.A., L.H.S.); Department of Neurology and Neurological Intensive Care, Staedtisches Klinikum München, TeleMedical Project for integrative Stroke Care, Munich, Germany (G.J.H.); Department of Neurology, Augusta University, GA (J.S., K.V.); Division of Vascular Neurology, University of Utah, Salt Lake City (J.J.M., L.W.S.); and Department of Neurology, University Regensburg, Germany (R.B.)
| | - Roland Backhaus
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.F.A., L.H.S.); Department of Neurology and Neurological Intensive Care, Staedtisches Klinikum München, TeleMedical Project for integrative Stroke Care, Munich, Germany (G.J.H.); Department of Neurology, Augusta University, GA (J.S., K.V.); Division of Vascular Neurology, University of Utah, Salt Lake City (J.J.M., L.W.S.); and Department of Neurology, University Regensburg, Germany (R.B.)
| | - L Wylie Shepard
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.F.A., L.H.S.); Department of Neurology and Neurological Intensive Care, Staedtisches Klinikum München, TeleMedical Project for integrative Stroke Care, Munich, Germany (G.J.H.); Department of Neurology, Augusta University, GA (J.S., K.V.); Division of Vascular Neurology, University of Utah, Salt Lake City (J.J.M., L.W.S.); and Department of Neurology, University Regensburg, Germany (R.B.)
| | - Kishore Vedala
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.F.A., L.H.S.); Department of Neurology and Neurological Intensive Care, Staedtisches Klinikum München, TeleMedical Project for integrative Stroke Care, Munich, Germany (G.J.H.); Department of Neurology, Augusta University, GA (J.S., K.V.); Division of Vascular Neurology, University of Utah, Salt Lake City (J.J.M., L.W.S.); and Department of Neurology, University Regensburg, Germany (R.B.)
| | - Lee H Schwamm
- From the Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (S.F.A., L.H.S.); Department of Neurology and Neurological Intensive Care, Staedtisches Klinikum München, TeleMedical Project for integrative Stroke Care, Munich, Germany (G.J.H.); Department of Neurology, Augusta University, GA (J.S., K.V.); Division of Vascular Neurology, University of Utah, Salt Lake City (J.J.M., L.W.S.); and Department of Neurology, University Regensburg, Germany (R.B.).
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26
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Yahia MM, Bashir S. Clinical Characteristics of Stroke Mimics Presenting to a Stroke Center within the Therapeutic Window of Thrombolysis. BRAIN & NEUROREHABILITATION 2018. [DOI: 10.12786/bn.2018.11.e9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Mohammed Mahgoub Yahia
- Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Neurosciences, Academic Neurosciences Centre, King's College London, London, UK
| | - Shahid Bashir
- Neuroscience Center, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
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27
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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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Casella G, Llinas RH, Marsh EB. Isolated aphasia in the emergency department: The likelihood of ischemia is low. Clin Neurol Neurosurg 2017; 163:24-26. [PMID: 29054018 DOI: 10.1016/j.clineuro.2017.10.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/10/2017] [Accepted: 10/15/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Aphasia is a common presentation of ischemic stroke, often diagnosed in the acute setting using tools such as the NIH Stroke Scale (NIHSS). Due to the vascular distribution of the middle cerebral artery, it is often accompanied by other symptoms such as weakness, sensory loss, or visual changes. Isolated aphasia due to ischemia is possible, but language problems mimicking aphasia syndromes can also be seen with other diagnoses such as metabolic abnormalities or dementia. In this study, we determine the incidence of aphasia-only strokes using the NIHSS, and factors associated with a higher likelihood of ischemia. PATIENTS AND METHODS Over a 2year period, 788 patients presented to our Emergency Department with symptoms of acute stroke. Data were collected regarding patient demographics, medical history, presenting symptoms (based on NIHSS), work-up results, and final diagnosis. The incidence of aphasia-only stroke was calculated. Student's t-tests and chi square analysis were used to determine factors associated with ischemia. RESULTS Of 788 patients, 21 (3%) presented with isolated "aphasia". None of the 21 had infarcts on neuroimaging. Three (14%) were diagnosed with possible transient ischemic attacks and the rest with stroke mimics. Toxic/metabolic disturbances were the most common mimics (39%). Prior history of stroke or transient ischemic attack was associated with ischemia over mimic (p=0.023). CONCLUSIONS Strokes affecting language without motor or sensory deficits are uncommon. In the acute setting, isolated "aphasia" is most often due to a stroke mimic; however can occur rarely, particularly in those with prior history of ischemia.
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Affiliation(s)
- Gabriel Casella
- Johns Hopkins School of Arts and Sciences, Baltimore MD, United States
| | - Rafael H Llinas
- Johns Hopkins School of Medicine, Baltimore MD, United States
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Quintas S, López Ruiz R, Trillo S, Gago-Veiga AB, Zapata-Wainberg G, Dotor García-Soto J, Ximénez-Carrillo Á, Vivancos J. Clinical, imaging and electroencephalographic characterization of three cases of HaNDL syndrome. Cephalalgia 2017; 38:1402-1406. [DOI: 10.1177/0333102417735846] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) may mimic stroke when patients present with acute/subacute focal neurological deficits. It would be helpful to identify investigations that assist the neurologist in differentiating between HaNDL and stroke. Case reports We describe three cases that proved to be HaNDL, but were initially considered to be strokes. Hypoperfusion was noted in the CT perfusion (CTP) studies in all three cases, which extended beyond any single cerebral arterial supply. The CTP findings suggested a stroke mimic, and there was no improvement on thrombolysis. MRI failed to show any abnormalities in diffusion and EEGs showed non-epileptiform changes. Lumbar punctures demonstrated a lymphocytic pleocytosis. Conclusion The diagnosis of HaNDL is based on clinical and CSF criteria, but neuroimaging, including CT perfusion, can be helpful in differentiating the clinical syndrome from stroke.
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Affiliation(s)
- Sonia Quintas
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Rocío López Ruiz
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Santiago Trillo
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Ana Beatriz Gago-Veiga
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Gustavo Zapata-Wainberg
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Julio Dotor García-Soto
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Álvaro Ximénez-Carrillo
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
| | - Jose Vivancos
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigaciœn Sanitaria La Princesa, Madrid, Spain
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Burton TM, Luby M, Nadareishvili Z, Benson RT, Lynch JK, Latour LL, Hsia AW. Effects of increasing IV tPA-treated stroke mimic rates at CT-based centers on clinical outcomes. Neurology 2017; 89:343-348. [PMID: 28659427 DOI: 10.1212/wnl.0000000000004149] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 05/01/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine to what degree stroke mimics skew clinical outcomes and the potential effects of incorrect stroke diagnosis. METHODS This retrospective analysis of data from 2005 to 2014 included IV tissue plasminogen activator (tPA)-treated adults with clinical suspicion for acute ischemic stroke who were transferred or admitted directly to our 2 hub hospitals. Primary outcome measures compared CT-based spoke hospitals' and MRI-based hub hospitals' mimic rates, hemorrhagic transformation, follow-up modified Rankin Scale (mRS), and discharge disposition. Secondary outcomes were compared over time. RESULTS Of the 725 thrombolysis-treated patients, 29% were at spoke hospitals and 71% at hubs. Spoke hospital patients differed from hubs by age (mean 62 ± 15 vs 72 ± 15 years, p < 0.0001), risk factors (atrial fibrillation, 17% vs 32%, p < 0.0001; alcohol consumption, 9% vs 4%, p = 0.007; smoking, 23% vs 13%, p = 0.001), and mimics (16% vs 0.6%, p < 0.0001). Inclusion of mimics resulted in better outcomes for spokes vs hubs by mRS ≤1 (40% vs 27%, p = 0.002), parenchymal hematoma type 2 (3% vs 7%, p = 0.037), and discharge home (47% vs 37%, p = 0.01). Excluding mimics, there were no significant differences. Comparing epochs, spoke stroke mimic rate doubled (9%-20%, p = 0.03); hub rate was unchanged (0%-1%, p = 0.175). CONCLUSIONS Thrombolysis of stroke mimics is increasing at our CT-based spoke hospitals and not at our MRI-based hub hospitals. Caution should be used in interpreting clinical outcomes based on large stroke databases when stroke diagnosis at discharge is unclear. Inadvertent reporting of treated stroke mimics as strokes will artificially elevate overall favorable clinical outcomes with additional downstream costs to patients and the health care system.
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Affiliation(s)
- Tina M Burton
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - Marie Luby
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - Zurab Nadareishvili
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - Richard T Benson
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - John K Lynch
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - Lawrence L Latour
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD
| | - Amie W Hsia
- From Stroke Diagnostics and Therapeutics Section (T.M.B., M.L., Z.N., R.T.B., J.K.L., L.L.L., A.W.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; MedStar Washington Hospital Center Comprehensive Stroke Center (R.T.B., A.W.H.), Washington, DC; and Suburban Hospital Stroke Center (Z.N.), Bethesda, MD.
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Delays in door-to-needle time for acute ischemic stroke in the emergency department: A comprehensive stroke center experience. J Neurol Sci 2017; 376:102-105. [DOI: 10.1016/j.jns.2017.03.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/19/2017] [Accepted: 03/02/2017] [Indexed: 11/22/2022]
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Mackay MT, Yock-Corrales A, Churilov L, Monagle P, Donnan GA, Babl FE. Accuracy and Reliability of Stroke Diagnosis in the Pediatric Emergency Department. Stroke 2017; 48:1198-1202. [PMID: 28336681 DOI: 10.1161/strokeaha.116.015571] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/20/2016] [Accepted: 01/13/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Access to acute stroke interventions in the emergency department (ED) relies on correct clinical diagnosis. Our aims were to determine the accuracy and reliability of pediatric ED physician diagnosis of childhood stroke and other conditions presenting with brain attack symptoms. METHODS Prospective study of consecutive children aged 1 month to 18 years presenting to the ED from June 2009 to December 2010 with focal neurological deficits. Accuracy (sensitivity, specificity, and receiver operator characteristic curves [ROCs]) and interrater agreement (κ) were determined, between ED physician diagnoses, as recorded in the electronic hospital administrative software system, and final neurological diagnosis, after completion of diagnostic work-up. RESULTS Two-hundred eighty-seven children with 301 consecutive presentations were recruited. The most common final brain attack diagnoses included migraine in 84 children, first seizure in 48, Bell's palsy in 29, stroke in 21, and conversion disorders in 18 children. Sensitivity of ED physician stroke diagnosis was 62%, and specificity was 98% (ROC, 0.8). Inter-rater agreement for ED physician and final stroke diagnosis was substantial (κ=0.61). ED physician diagnostic accuracy and reliability was highest for Bell's palsy (ROC=0.98; κ=0.96), and lowest for central nervous system demyelination (ROC=0.5; κ=-0.01) and cerebellitis (ROC=0.50; κ=0.50). CONCLUSIONS ED physician diagnostic accuracy and reliability varies considerably across disorders presenting with brain attack symptoms. Clinical recognition tools are required to assist pediatric ED physicians with diagnosis of stroke and other serious neurological disorders.
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Affiliation(s)
- Mark T Mackay
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.).
| | - Adriana Yock-Corrales
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.)
| | - Leonid Churilov
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.)
| | - Paul Monagle
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.)
| | - Geoffrey A Donnan
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.)
| | - Franz E Babl
- From the Department of Neurology (M.T.M.), Department of Haematology (P.M.), and Emergency Department (F.B.), Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia (M.T.M., F.B.); Florey Institute of Neurosciences and Mental Health, Parkville, Victoria, Australia (M.T.M., L.C., G.A.D.); University of Melbourne, Parkville, Victoria, Australia (M.T.M., L.C., P.M., G.A.D., F.B.); and Emergency Department, Hospital Nacional de Ninos, San Jose, Costa Rica (A.Y.-C.)
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Demeestere J, Sewell C, Rudd J, Ang T, Jordan L, Wills J, Garcia-Esperon C, Miteff F, Krishnamurthy V, Spratt N, Lin L, Bivard A, Parsons M, Levi C. The establishment of a telestroke service using multimodal CT imaging decision assistance: "Turning on the fog lights". J Clin Neurosci 2016; 37:1-5. [PMID: 27887976 DOI: 10.1016/j.jocn.2016.10.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/15/2016] [Indexed: 11/25/2022]
Abstract
Telestroke services have been shown to increase stroke therapy access in rural areas. The implementation of advanced CT imaging for patient assessment may improve patient selection and detection of stroke mimics in conjunction with telestroke. We implemented a telestroke service supported by multimodal CT imaging in a rural hospital in Australia. Over 21months we conducted an evaluation of service activation, thrombolysis rates and use of multimodal imaging to assess the feasibility of the service. Rates of symptomatic intracranial haemorrhage and 90-day modified Rankin Score were used as safety outcomes. Fifty-eight patients were assessed using telestroke, of which 41 were regarded to be acute ischemic strokes and 17 to be stroke mimics on clinical grounds. Of the 41 acute stroke patients, 22 patients were deemed eligible for thrombolysis. Using multimodal CT imaging, 8 more patients were excluded from treatment because of lack of treatment target. Multimodal imaging failed to be obtained in one patient. For the 14 treated patients, median door-imaging time was 38min. Median door-treatment time was 91min. A 90-day mRS ⩽2 was achieved in 40% of treated patients. We conclude that a telestroke service using advanced CT imaging for therapy decision assistance can be successfully implemented in regional Australia and can be used to guide acute stroke treatment decision-making and improve access to thrombolytic therapy. Efficiency and safety is comparable to established telestroke services.
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Affiliation(s)
| | - Claire Sewell
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Jennifer Rudd
- Manning Rural Referral Hospital, Taree, NSW, Australia
| | - Timothy Ang
- John Hunter Hospital, Newcastle, NSW, Australia
| | - Louise Jordan
- Hunter Stroke Service, Hunter New England Health, Newcastle, NSW, Australia
| | - James Wills
- Manning Rural Referral Hospital, Taree, NSW, Australia
| | | | | | | | - Neil Spratt
- John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, Callaghan, NSW, Australia
| | - Longting Lin
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Andrew Bivard
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Mark Parsons
- John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, Callaghan, NSW, Australia
| | - Christopher Levi
- John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, Callaghan, NSW, Australia.
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ASL and susceptibility-weighted imaging contribution to the management of acute ischaemic stroke. Insights Imaging 2016; 8:91-100. [PMID: 27822669 PMCID: PMC5265193 DOI: 10.1007/s13244-016-0529-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 09/19/2016] [Accepted: 10/03/2016] [Indexed: 12/04/2022] Open
Abstract
Abstract Magnetic resonance imaging (MRI) plays a central role in the early diagnosis of cerebral vascular events. Today, MRI is used not only for the detection of acute ischaemic lesions, but also to fine tune the diagnosis and improve patient selection for early therapeutic decision-making. In this perspective, new tools such as arterial spin labelling (ASL) and susceptibility-weighted imaging (SWI) sequences have been developed. These MRI sequences enable noninvasive assessment of brain damage, providing important diagnostic and prognostic information: evaluation of cerebral parenchymal perfusion; detection and aetiological assessment of thrombi; ruling out differential diagnoses. After a brief recall of the fundamental basis of these sequences, this article proposes an update on their current contribution to the early management of stroke victims. Teaching Points • These noninvasive sequences provide essential information for early management of acute stroke. • They can detect zones of parenchymal hypoperfusion. • Susceptibility-weighted sequences provide information on thrombus localisation and composition. • ASL can identify certain aetiologies of stroke mimics. • Post-therapeutic ASL perfusion status predicts outcome.
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Zhu W, Xiao L, Lin M, Liu X, Yan B. Large-Vessel Occlusion Is Associated with Poor Outcome in Stroke Patients Aged 80 Years or Older Who Underwent Intravenous Thrombolysis. J Stroke Cerebrovasc Dis 2016; 25:2712-2716. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/14/2016] [Accepted: 07/10/2016] [Indexed: 11/30/2022] Open
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Myslimi F, Caparros F, Dequatre-Ponchelle N, Moulin S, Gautier S, Girardie P, Cordonnier C, Bordet R, Leys D. Orolingual Angioedema During or After Thrombolysis for Cerebral Ischemia. Stroke 2016; 47:1825-30. [DOI: 10.1161/strokeaha.116.013334] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/27/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Orolingual angioedema (OLAE) is a life-threatening complication of intravenous thrombolysis. Our objective was to compare outcomes of patients with and without OLAE.
Methods—
We prospectively included consecutive patients who received intravenous thrombolysis for cerebral ischemia at Lille University Hospital. We examined tongue and lips every 15 minutes during thrombolysis and ≤30 minutes after. We evaluated the 3-month outcome with the modified Rankin scale (mRS) and compared outcomes of patients with and without OLAE.
Results—
Of 923 consecutive patients, 20 (2.2%) developed OLAE. None of them needed oro-tracheal intubation. They were more likely to be under angiotensin-converting enzyme inhibitors (adjusted odds ratio [adjOR], 3.9; 95% confidence interval [CI], 1.6–9.7;
P
=0.005) to have total insular infarcts (OR, 5.0; 95% CI, 1.5–16.5;
P
=0.004) and tended to develop more symptomatic intracerebral hemorrhages. Results concerning angiotensin-converting enzyme inhibitors were not modified after adjustment for propensity scores (OR, 4.4; 95% CI, 1.6–11.9;
P
=0.004) or matched analysis based on propensity scores (OR, 3.4; 95% CI, 1.3–8.1;
P
=0.010). Patients with OLAE did not significantly differ at 3 months for the proportion of patients with mRS score of 0 to 1 (adjOR, 0.9; 95% CI, 0.3–2.1), mRS score of 0 to 2 (adjOR, 0.8; 95% CI, 0.1–1.8), and death (adjOR, 1.1; 95% CI, 0.3–3.8).
Conclusions—
OLAE occurs in 1 of 50 patients who receive intravenous thrombolysis, 1 of 10 in case of total insular infarct, and 1 of 6 if they are under angiotensin-converting enzyme inhibitors. Their long-term outcome does not differ from that of other patients.
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Affiliation(s)
- Fjorda Myslimi
- From the Departments of Neurology (F.M., F.C., N.D.-P., S.M., C.C., D.L.), Intensive Care Medicine (P.G.), and Pharmacology (S.G., R.B.), University Lille 2, Lille, France; INSERM U 1171, Lille University Hospital (S.M., S.G., C.C., R.B., D.L.), Lille, France; and University of Medicine of Tirana, Tirana, Albania (F.M.)
| | - François Caparros
- From the Departments of Neurology (F.M., F.C., N.D.-P., S.M., C.C., D.L.), Intensive Care Medicine (P.G.), and Pharmacology (S.G., R.B.), University Lille 2, Lille, France; INSERM U 1171, Lille University Hospital (S.M., S.G., C.C., R.B., D.L.), Lille, France; and University of Medicine of Tirana, Tirana, Albania (F.M.)
| | - Nelly Dequatre-Ponchelle
- From the Departments of Neurology (F.M., F.C., N.D.-P., S.M., C.C., D.L.), Intensive Care Medicine (P.G.), and Pharmacology (S.G., R.B.), University Lille 2, Lille, France; INSERM U 1171, Lille University Hospital (S.M., S.G., C.C., R.B., D.L.), Lille, France; and University of Medicine of Tirana, Tirana, Albania (F.M.)
| | - Solène Moulin
- From the Departments of Neurology (F.M., F.C., N.D.-P., S.M., C.C., D.L.), Intensive Care Medicine (P.G.), and Pharmacology (S.G., R.B.), University Lille 2, Lille, France; INSERM U 1171, Lille University Hospital (S.M., S.G., C.C., R.B., D.L.), Lille, France; and University of Medicine of Tirana, Tirana, Albania (F.M.)
| | - Sophie Gautier
- From the Departments of Neurology (F.M., F.C., N.D.-P., S.M., C.C., D.L.), Intensive Care Medicine (P.G.), and Pharmacology (S.G., R.B.), University Lille 2, Lille, France; INSERM U 1171, Lille University Hospital (S.M., S.G., C.C., R.B., D.L.), Lille, France; and University of Medicine of Tirana, Tirana, Albania (F.M.)
| | - Patrick Girardie
- From the Departments of Neurology (F.M., F.C., N.D.-P., S.M., C.C., D.L.), Intensive Care Medicine (P.G.), and Pharmacology (S.G., R.B.), University Lille 2, Lille, France; INSERM U 1171, Lille University Hospital (S.M., S.G., C.C., R.B., D.L.), Lille, France; and University of Medicine of Tirana, Tirana, Albania (F.M.)
| | - Charlotte Cordonnier
- From the Departments of Neurology (F.M., F.C., N.D.-P., S.M., C.C., D.L.), Intensive Care Medicine (P.G.), and Pharmacology (S.G., R.B.), University Lille 2, Lille, France; INSERM U 1171, Lille University Hospital (S.M., S.G., C.C., R.B., D.L.), Lille, France; and University of Medicine of Tirana, Tirana, Albania (F.M.)
| | - Régis Bordet
- From the Departments of Neurology (F.M., F.C., N.D.-P., S.M., C.C., D.L.), Intensive Care Medicine (P.G.), and Pharmacology (S.G., R.B.), University Lille 2, Lille, France; INSERM U 1171, Lille University Hospital (S.M., S.G., C.C., R.B., D.L.), Lille, France; and University of Medicine of Tirana, Tirana, Albania (F.M.)
| | - Didier Leys
- From the Departments of Neurology (F.M., F.C., N.D.-P., S.M., C.C., D.L.), Intensive Care Medicine (P.G.), and Pharmacology (S.G., R.B.), University Lille 2, Lille, France; INSERM U 1171, Lille University Hospital (S.M., S.G., C.C., R.B., D.L.), Lille, France; and University of Medicine of Tirana, Tirana, Albania (F.M.)
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Bhatt A, Lesko A, Lucas L, Kansara A, Baraban E. Patients with Low National Institutes of Health Stroke Scale Scores Have Longer Door-to-Needle Times: Analysis of a Telestroke Network. J Stroke Cerebrovasc Dis 2016; 25:2253-8. [PMID: 27266620 DOI: 10.1016/j.jstrokecerebrovasdis.2016.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 04/30/2016] [Accepted: 05/04/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND The benefits of intravenous tissue-type plasminogen activator (IV-tPA) in acute ischemic stroke (AIS) are time dependent. Because emergency rooms quickly initiate a stroke alert with more severe symptoms, we hypothesized that patients with lower National Institutes of Health Stroke Scale (NIHSS) scores, indicating a less severe stroke, would have longer door-to-needle (DTN) times compared to patients with higher NIHSS scores. METHODS Data obtained from the 19-hospital Providence Stroke Registry were used to identify AIS patients who received IV-tPA within 4.5 hours of last-known-well. NIHSS scores were obtained prior to tPA administration at the time of emergency department presentation and categorized as low-NIHSS (score = 0-5) or high-NIHSS (score = 6-42) strokes. Median DTN times were collected for both groups as the primary outcome variable. Linear mixed-effects regression models were used to assess the effect of NIHSS scores on DTN and its 2 components: door-to-CT (DCT) and CT-to-needle (CTN) times. RESULTS We identified 692 AIS patients who received IV-tPA within 4.5 hours of last-known-well, with 198 patients presenting with low-NIHSS strokes and 494 patients with high-NIHSS strokes. In multivariable analysis, median DTN time was estimated to be 18% higher for low-NIHSS strokes than high-NIHSS strokes after adjusting for covariates (P < .001). Median DCT times were also higher for low-NIHSS (19 minutes) compared to high-NIHSS (11 minutes) strokes after adjusting for covariates (P < .001), whereas CTN times were unchanged (P = .055). CONCLUSION In AIS patients receiving IV-tPA in a telestroke network, lower NIHSS scores were associated with longer DTN and DCT times.
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Affiliation(s)
- Archit Bhatt
- Providence Brain and Spine Institute, Portland, Oregon.
| | | | - Lindsay Lucas
- Providence Brain and Spine Institute, Portland, Oregon
| | - Amit Kansara
- Providence Brain and Spine Institute, Portland, Oregon
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Spalice A, Del Balzo F, Papetti L, Zicari AM, Properzi E, Occasi F, Nicita F, Duse M. Stroke and migraine is there a possible comorbidity? Ital J Pediatr 2016; 42:41. [PMID: 27113086 PMCID: PMC4845315 DOI: 10.1186/s13052-016-0253-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/12/2016] [Indexed: 11/18/2022] Open
Abstract
The association between migraine and stroke is still a dilemma for neurologists. Migraine is associated with an increased stroke risk and it is considered an independent risk factor for ischaemic stroke in a particular subgroup of patients. The pathogenesis is still unknown even if several studies report some common biochemical mechanisms between these two diseases. A classification of migraine-related stroke that encompasses the full spectrum of the possible relationship between migraine and stroke includes three main entities: coexisting stroke and migraine, stroke with clinical features of migraine, and migraine-induced stroke. The concept of migraine-induced stroke is well represented by migrainous infarction and it is described in the revised classification of the International Headache Society (IHS), representing the strongest demonstration of the relationship between ischaemic stroke and migraine. A very interesting common condition in stroke and migraine is patent foramen ovale (PFO) which could play a pathogenetic role in both disorders. The neuroradiological evidence of subclinical lesions most typical in the white matter and in the posterior artery territories in patients with migraine, opens a new field of research. In conclusion the association between migraine and stroke remains an open question. Solving the above mentioned issues is fundamental to understand the epidemiologic, pathogenetic and clinical aspects of migraine-related stroke.
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Affiliation(s)
- Alberto Spalice
- Department of Pediatrics Child Neurology Division, Sapienza University Rome, Viale Regina Elena 324, 00161, Roma, Italy.
| | - Francesca Del Balzo
- Department of Pediatrics Child Neurology Division, Sapienza University Rome, Viale Regina Elena 324, 00161, Roma, Italy
| | - Laura Papetti
- Department of Pediatrics Child Neurology Division, Sapienza University Rome, Viale Regina Elena 324, 00161, Roma, Italy
| | - Anna Maria Zicari
- Department of Pediatrics Child Neurology Division, Sapienza University Rome, Viale Regina Elena 324, 00161, Roma, Italy
| | - Enrico Properzi
- Department of Pediatrics Child Neurology Division, Sapienza University Rome, Viale Regina Elena 324, 00161, Roma, Italy
| | - Francesca Occasi
- Department of Pediatrics Child Neurology Division, Sapienza University Rome, Viale Regina Elena 324, 00161, Roma, Italy
| | - Francesco Nicita
- Department of Pediatrics Child Neurology Division, Sapienza University Rome, Viale Regina Elena 324, 00161, Roma, Italy
| | - Marzia Duse
- Department of Pediatrics Child Neurology Division, Sapienza University Rome, Viale Regina Elena 324, 00161, Roma, Italy
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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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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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Abstract
Efforts are underway to develop novel platforms for stroke diagnosis to meet the criteria for effective treatment within the narrow time window mandated by the FDA-approved therapeutic (<3 h). Blood-based biomarkers could be used for rapid stroke diagnosis and coupled with new analytical tools, could serve as an attractive platform for managing stroke-related diseases. In this review, we will discuss the physiological processes associated with stroke and current diagnostic tools as well as their associated shortcomings. We will then review information on blood-based biomarkers and various detection technologies. In particular, point of care testing that permits small blood volumes required for the analysis and rapid turn-around time measurements of multiple markers will be presented.
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Tsivgoulis G, Safouris A, Alexandrov AV. Safety of intravenous thrombolysis for acute ischemic stroke in specific conditions. Expert Opin Drug Saf 2015; 14:845-64. [DOI: 10.1517/14740338.2015.1032242] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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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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Abstract
PURPOSE OF REVIEW To summarize what is known about the use of MRI in acute stroke treatment (predominantly thrombolysis), to examine the assumptions and theories behind the interpretation of magnetic resonance images of acute ischemic stroke and how they are used to select patients for therapies, and to suggest directions for future research. RECENT FINDINGS Recent studies have been contradictory about the usefulness of MRI in selecting patients for treatment. New MRI models for selecting patients have emerged that focus not only on the ischemic penumbra but also on the infarct core. Fixed time-window selection parameters are being replaced by timing-based individualized MRI stroke features. New ways to interpret traditional MRI stroke sequences are emerging. SUMMARY Although the efficacy of acute stroke treatment is time dependent, the use of fixed time windows cannot account for individual differences in infarct evolution, which could potentially be detected with MRI. Although MRI shows promise for identifying patients who should be treated, as well as excluding patients who should not be treated, definitive evidence is still lacking. Future research should focus on validating the use of MRI to select patients for intravenous therapies in extended time windows.
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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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Correia AS, Matias G, Calado S, Lourenço A, Viana-Baptista M. Orolingual Angiodema Associated with Alteplase Treatment of Acute Stroke: A Reappraisal. J Stroke Cerebrovasc Dis 2015; 24:31-40. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 06/24/2014] [Accepted: 07/26/2014] [Indexed: 10/24/2022] Open
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Zhu W, Churilov L, Campbell BC, Lin M, Liu X, Davis SM, Yan B. Does Large Vessel Occlusion Affect Clinical Outcome in Stroke with Mild Neurologic Deficits after Intravenous Thrombolysis? J Stroke Cerebrovasc Dis 2014; 23:2888-2893. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/28/2014] [Accepted: 07/11/2014] [Indexed: 11/29/2022] Open
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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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De Los Rios F, Kleindorfer DO, Guzik A, Ortega-Gutierrez S, Sangha N, Kumar G, Grotta JC, Lee JM, Meyer BC, Schwamm LH, Khatri P. Intravenous fibrinolysis eligibility: a survey of stroke clinicians' practice patterns and review of the literature. J Stroke Cerebrovasc Dis 2014; 23:2130-2138. [PMID: 25113084 DOI: 10.1016/j.jstrokecerebrovasdis.2014.03.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 03/29/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The indications and contraindications for intravenous (IV) recombinant tissue plasminogen activator (rtPA) use in ischemic stroke can be confusing to the practicing neurologist. Here we seek to describe practice patterns regarding decision-making among US stroke clinicians. METHODS Stroke clinicians (attending and fellow) from the 8 National Institutes of Health SPOTRIAS (Specialized Programs of Translational Research in Acute Stroke) centers were asked to complete a survey ahead of the 2012 SPOTRIAS Investigators' meeting. RESULTS A total of 51 surveys were collected (71% response rate). Most of the responders were attending physicians (68%). Only 18% of clinicians reported strictly adhering to current American Heart Association guidelines for treatment within 3 hours from symptom onset; this increased to 51% for the European Cooperative Acute Stroke Study (ECASS) III criteria in the 3 to 4.5 hours time frame. All clinicians treat eligible patients in the 3 to 4.5 hours time frame. The great majority will recommend rtPA in the following scenarios: (1) elderly individuals irrespective of age (97%); (2) severe stroke irrespective of National Institutes of Health Stroke Scale (NIHSS) (95%); or (3) suspected stroke with seizures at symptom onset (91%). None recommended rtPA in the setting of an international normalized ratio >1.7. Most clinicians defined mild strokes as an exclusion based on the perceived disability of the deficit (80%) rather than on a specific NIHSS threshold. CONCLUSIONS Most surveyed stroke clinicians seem to find that the current IV rtPA eligibility criteria for the 3-hour time frame too restrictive. All would recommend rtPA to eligible patients in the 3 to 4.5 hours time frame despite the absence of an U.S. Food and Drug Administration (FDA)-approved indication.
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Affiliation(s)
- Felipe De Los Rios
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Neurology, Sanna Healthcare Network, Lima, Peru.
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amy Guzik
- Department of Neuroscience, University of California San Diego, San Diego, California
| | | | - Navdeep Sangha
- Department of Neurology, University of Texas, Houston, Texas
| | - Gyanendra Kumar
- Department of Neurology, Washington University, St. Louis, Missouri
| | - James C Grotta
- Department of Neurology, University of Texas, Houston, Texas
| | - Jin-Moo Lee
- Department of Neurology, Washington University, St. Louis, Missouri
| | - Brett C Meyer
- Department of Neuroscience, University of California San Diego, San Diego, California
| | - Lee H Schwamm
- Department of Neurology, Harvard Medical School, Boston, Massachussets
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Ali SF, Viswanathan A, Singhal AB, Rost NS, Forducey PG, Davis LW, Schindler J, Likosky W, Schlegel S, Solenski N, Schwamm LH. The TeleStroke mimic (TM)-score: a prediction rule for identifying stroke mimics evaluated in a Telestroke Network. J Am Heart Assoc 2014; 3:e000838. [PMID: 24958778 PMCID: PMC4309074 DOI: 10.1161/jaha.114.000838] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Up to 30% of acute stroke evaluations are deemed stroke mimics (SM). As telestroke consultation expands across the world, increasing numbers of SM patients are likely being evaluated via Telestroke. We developed a model to prospectively identify ischemic SMs during Telestroke evaluation. Methods and Results We analyzed 829 consecutive patients from January 2004 to April 2013 in our internal New England–based Partners TeleStroke Network for a derivation cohort, and 332 cases for internal validation. External validation was performed on 226 cases from January 2008 to August 2012 in the Partners National TeleStroke Network. A predictive score was developed using stepwise logistic regression, and its performance was assessed using receiver‐operating characteristic (ROC) curve analysis. There were 23% SM in the derivation, 24% in the internal, and 22% in external validation cohorts based on final clinical diagnosis. Compared to those with ischemic cerebrovascular disease (iCVD), SM had lower mean age, fewer vascular risk factors, more frequent prior seizure, and a different profile of presenting symptoms. The TeleStroke Mimic Score (TM‐Score) was based on factors independently associated with SM status including age, medical history (atrial fibrillation, hypertension, seizures), facial weakness, and National Institutes of Health Stroke Scale >14. The TM‐Score performed well on ROC curve analysis (derivation cohort AUC=0.75, internal validation AUC=0.71, external validation AUC=0.77). Conclusions SMs differ substantially from their iCVD counterparts in their vascular risk profiles and other characteristics. Decision‐support tools based on predictive models, such as our TM Score, may help clinicians consider alternate diagnosis and potentially detect SMs during complex, time‐critical telestroke evaluations.
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Affiliation(s)
- Syed F Ali
- Massachusetts General Hospital/Harvard Medical School, Boston, MA (S.F.A., A.V., A.B.S., N.S.R., L.H.S.)
| | - Anand Viswanathan
- Massachusetts General Hospital/Harvard Medical School, Boston, MA (S.F.A., A.V., A.B.S., N.S.R., L.H.S.)
| | - Aneesh B Singhal
- Massachusetts General Hospital/Harvard Medical School, Boston, MA (S.F.A., A.V., A.B.S., N.S.R., L.H.S.)
| | - Natalia S Rost
- Massachusetts General Hospital/Harvard Medical School, Boston, MA (S.F.A., A.V., A.B.S., N.S.R., L.H.S.)
| | | | | | | | | | | | | | - Lee H Schwamm
- Massachusetts General Hospital/Harvard Medical School, Boston, MA (S.F.A., A.V., A.B.S., N.S.R., L.H.S.)
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