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Giovannini G, Malagoli M, Turchi G, Miani A, Orlandi N, Vaudano AE, Meletti S. Cortical and thalamic hyper-perfusion in non-convulsive status epilepticus. Relationship between perfusion CT patterns and Salzburg EEG criteria. Seizure 2021; 92:10-17. [PMID: 34391029 DOI: 10.1016/j.seizure.2021.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency and in particular nonconvulsive SE (NCSE) represents a diagnostic challenge. To improve clinical decision-making, cerebral perfusion-computed tomography (PCT) has been shown as a helpful tool to support the diagnosis of focal NCSE. MATERIALS AND METHODS This is a monocentric retrospective study. Among the 602 cases of SE observed between September 2013 and April 2020 we included 21 patients that were studied with PCT. The perfusion maps were first visually analysed then a quantitative analysis (by regions of interest, ROI) was obtained. For each patient, the diagnostic EEG was reviewed and classified in accordance to the Salzburg Criteria for NCSE (SCC) as definite (D-NCSE) and possible (P-NCSE). Finally, we analysed the relationship between PCT and EEG patterns. RESULTS Hyper-perfusion was observed in 18 patients (86%), while in the remaining 3 (14%) a normo-perfused pattern was present. Hyper-perfusion was observed in 14 of the D-NCSE group (88%) and in the two patients with a P-NCSE (100%). No one among the patients with a P-NCSE had a thalamic hyper-perfusion, while among the 6 patients with continuous sustained epileptiform discharges > 2.5 Hz (pattern 1 of SCC), 4 (67%) showed cortical plus thalamic hyper-perfusion. CONCLUSIONS PCT could facilitate the differential diagnosis and speed-up the diagnostic process of NCSE in emergency situations. Finding cortical multi-lobar hyper-perfusion, especially if present together with homolateral thalamic hyper-perfusion in a patient with an acute-onset of motor/sensory/language deficits is highly suggestive for the presence of NCSE and is particularly related to continuous/sustained ictal patterns.
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Affiliation(s)
- Giada Giovannini
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy; PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Marcella Malagoli
- Neuroradiology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy
| | - Giulia Turchi
- Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy
| | - Alice Miani
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Orlandi
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy
| | | | - Stefano Meletti
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy.
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Khoo CS, Kim SE, Lee BI, Shin KJ, Ha SY, Park J, Park KM, Bae SY, Lee D, Kim BJ, Bae MJ, Kim SE. Characteristics of Perfusion Computed Tomography Imaging in Patients with Seizures Mimicking Acute Stroke. Eur Neurol 2020; 83:56-64. [DOI: 10.1159/000506591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/15/2020] [Indexed: 11/19/2022]
Abstract
Introduction: Seizures as acute stroke mimics are a diagnostic challenge. Objective: The aim of the study was to characterize the perfusion patterns on perfusion computed tomography (PCT) in patients with seizures masquerading as acute stroke. Methods: We conducted a study on patients with acute seizures as stroke mimics. The inclusion criteria for this study were patients (1) initially presenting with stroke-like symptoms but finally diagnosed to have seizures and (2) with PCT performed within 72 h of seizures. The PCT of seizure patients (n = 27) was compared with that of revascularized stroke patients (n = 20) as the control group. Results: Among the 27 patients with seizures as stroke mimics, 70.4% (n = 19) showed characteristic PCT findings compared with the revascularized stroke patients, which were as follows: (1) multi-territorial cortical hyperperfusion {(73.7% [14/19] vs. 0% [0/20], p = 0.002), sensitivity of 73.7%, negative predictive value (NPV) of 80%}, (2) involvement of the ipsilateral thalamus {(57.9% [11/19] vs. 0% [0/20], p = 0.007), sensitivity of 57.9%, NPV of 71.4%}, and (3) reduced perfusion time {(84.2% [16/19] vs. 0% [0/20], p = 0.001), sensitivity of 84.2%, NPV of 87%}. These 3 findings had 100% specificity and positive predictive value in predicting patients with acute seizures in comparison with reperfused stroke patients. Older age was strongly associated with abnormal perfusion changes (p = 0.038), with a mean age of 66.8 ± 14.5 years versus 49.2 ± 27.4 years (in seizure patients with normal perfusion scan). Conclusions: PCT is a reliable tool to differentiate acute seizures from acute stroke in the emergency setting.
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The role of CT perfusion in the evaluation of seizures, the post-ictal state, and status epilepticus. Epilepsy Res 2020; 159:106256. [DOI: 10.1016/j.eplepsyres.2019.106256] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 11/17/2019] [Accepted: 12/09/2019] [Indexed: 01/11/2023]
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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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González‐Cuevas M, Coscojuela P, Santamarina E, Pareto D, Quintana M, Sueiras M, Guzman L, Sarria S, Salas‐Puig X, Toledo M, Rovira À. Usefulness of brain perfusion CT in focal‐onset status epilepticus. Epilepsia 2019; 60:1317-1324. [DOI: 10.1111/epi.16063] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 05/14/2019] [Accepted: 05/15/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Montserrat González‐Cuevas
- Epilepsy Unit Neurology Department Hospital Universitari Vall d'Hebron Barcelona Spain
- Department of Medicine Universitat Autonoma de Barcelona Barcelona Spain
| | - Pilar Coscojuela
- Neuroradiology Section Radiology Department Hospital Universitari Vall d'Hebron Barcelona Spain
| | - Estevo Santamarina
- Epilepsy Unit Neurology Department Hospital Universitari Vall d'Hebron Barcelona Spain
- Department of Medicine Universitat Autonoma de Barcelona Barcelona Spain
| | - Deborah Pareto
- Neuroradiology Section Radiology Department Hospital Universitari Vall d'Hebron Barcelona Spain
| | - Manuel Quintana
- Epilepsy Unit Neurology Department Hospital Universitari Vall d'Hebron Barcelona Spain
- Department of Medicine Universitat Autonoma de Barcelona Barcelona Spain
| | - María Sueiras
- Neurophysiology Unit Hospital Universitari Vall d'Hebron Barcelona Spain
| | - Lorena Guzman
- Neurophysiology Unit Hospital Universitari Vall d'Hebron Barcelona Spain
| | - Silvana Sarria
- Neuroradiology Section Radiology Department Hospital Universitari Vall d'Hebron Barcelona Spain
| | - Xavier Salas‐Puig
- Epilepsy Unit Neurology Department Hospital Universitari Vall d'Hebron Barcelona Spain
- Department of Medicine Universitat Autonoma de Barcelona Barcelona Spain
| | - Manuel Toledo
- Epilepsy Unit Neurology Department Hospital Universitari Vall d'Hebron Barcelona Spain
- Department of Medicine Universitat Autonoma de Barcelona Barcelona Spain
| | - Àlex Rovira
- Neuroradiology Section Radiology Department Hospital Universitari Vall d'Hebron Barcelona Spain
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Usefulness of multiparametric computerised tomography findings in the differential diagnosis of stroke mimics of epileptic origin: A preliminary study. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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López Ruiz R, Quintas S, Largo P, de Toledo M, Carreras M, Gago-Veiga A, Manzanares R, Vivancos J. Utilidad de la tomografía computarizada cerebral multiparamétrica en el diagnóstico diferencial de patología comicial en el código ictus. Estudio preliminar. Neurologia 2019; 34:73-79. [DOI: 10.1016/j.nrl.2016.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/25/2016] [Accepted: 10/29/2016] [Indexed: 10/20/2022] Open
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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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Nandal S, Castles A, Asrar Ul Haq M, van Gaal W. Takotsubo cardiomyopathy triggered by status epilepticus: case report and literature review. BMJ Case Rep 2019; 12:12/1/e225924. [PMID: 30700451 DOI: 10.1136/bcr-2018-225924] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Takotsubo cardiomyopathy (TC) is acute stress-induced cardiomyopathy with characteristic transient wall motion abnormalities. TC has a clinical presentation similar to an acute coronary syndrome, including chest pain or dyspnoea, ECG changes and elevated cardiac enzymes. TC often occurs after emotional stress. There are approximately 50 TC cases reported related to seizure activity, and our review revealed 15 articles which were associated with status epilepticus. This condition can be a serious complication of seizures. We report a case of TC after status epilepticus in a patient who had been seizure-free for 20 years.
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Affiliation(s)
- Savvy Nandal
- Department of Cardiology, The Northern Health, Epping, Victoria, Australia
| | - Anastasia Castles
- Department of Cardiology, The Northern Health, Epping, Victoria, Australia
| | | | - William van Gaal
- Department of Cardiology, The Northern Health, Epping, Victoria, Australia
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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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Austein F, Huhndorf M, Meyne J, Laufs H, Jansen O, Lindner T. Advanced CT for diagnosis of seizure-related stroke mimics. Eur Radiol 2017; 28:1791-1800. [DOI: 10.1007/s00330-017-5174-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/25/2017] [Accepted: 11/06/2017] [Indexed: 12/19/2022]
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Kubiak-Balcerewicz K, Fiszer U, Nagańska E, Siemianowski C, Sobieszek A, Witak-Grzybowska A, Kosińska-Szot A. Differentiating Stroke and Seizure in Acute Setting—Perfusion Computed Tomography? J Stroke Cerebrovasc Dis 2017; 26:1321-1327. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 01/12/2017] [Accepted: 02/03/2017] [Indexed: 02/07/2023] Open
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Abstract
Both stroke and seizures have varied clinical presentations and their differentiation in the acute setting is not always straightforward. We present the case of a patient who presented at the emergency room with acute onset aphasia. Clinically acute ischemic stroke was suspected. Perfusion CT was performed and demonstrated cortical hypervascularity in the left partietotemporal region. Additional MRI and EEG were performed and a final diagnosis of postictal aphasia was made. This case illustrates that perfusion CT is not only a useful tool for acute stroke management, but can also aid in the detection of seizures in patients presenting with stroke-like symptoms.
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Balami JS, Hadley G, Sutherland BA, Karbalai H, Buchan AM. The exact science of stroke thrombolysis and the quiet art of patient selection. ACTA ACUST UNITED AC 2013; 136:3528-53. [PMID: 24038074 DOI: 10.1093/brain/awt201] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The science of metric-based patient stratification for intravenous thrombolysis, revolutionized by the landmark National Institute of Neurological Disorders and Stroke trial, has transformed acute ischaemic stroke therapy. Recanalization of an occluded artery produces tissue reperfusion that unequivocally improves outcome and function in patients with acute ischaemic stroke. Recanalization can be achieved mainly through intravenous thrombolysis, but other methods such as intra-arterial thrombolysis or mechanical thrombectomy can also be employed. Strict guidelines preclude many patients from being treated by intravenous thrombolysis due to the associated risks. The quiet art of informed patient selection by careful assessment of patient baseline factors and brain imaging could increase the number of eligible patients receiving intravenous thrombolysis. Outside of the existing eligibility criteria, patients may fall into therapeutic 'grey areas' and should be evaluated on a case by case basis. Important factors to consider include time of onset, age, and baseline blood glucose, blood pressure, stroke severity (as measured by National Institutes of Health Stroke Scale) and computer tomography changes (as measured by Alberta Stroke Programme Early Computed Tomography Score). Patients with traditional contraindications such as wake-up stroke, malignancy or dementia may have the potential to receive benefit from intravenous thrombolysis if they have favourable predictors of outcome from both clinical and imaging criteria. A proportion of patients experience complications or do not respond to intravenous thrombolysis. In these patients, other endovascular therapies or a combination of both may be used to provide benefit. Although an evidence-based approach to intravenous thrombolysis for acute ischaemic stroke is pivotal, it is imperative to examine those who might benefit outside of protocol-driven practice.
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Affiliation(s)
- Joyce S Balami
- 1 Acute Stroke Programme, Department of Medicine and Clinical Geratology, Oxford University Hospitals NHS Trust, Oxford, UK
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