Metabolic disorders presenting as stroke

Acute Acquired Metabolic Encephalopathy Based on Diffusion MRI

Metabolic encephalopathy is a critical condition that can be challenging to diagnose. Imaging provides early clues to confirm clinical suspicions and plays an important role in the diagnosis, assessment of the response to therapy, and prognosis prediction. Diffusion-weighted imaging is a sensitive technique used to evaluate metabolic encephalopathy at an early stage. Metabolic encephalopathies often involve the deep regions of the gray matter because they have high energy requirements and are susceptible to metabolic disturbances. Understanding the imaging patterns of various metabolic encephalopathies can help narrow the differential diagnosis and improve the prognosis of patients by initiating proper treatment regimen early.

Changing Demographics of Stroke Mimics in Present Day Stroke Code Era: Need of a Streamlined Clinical Assessment for Emergency Physicians

Background  There is an apparently high incidence of stroke mimics in the present-day stroke code era. The reason being is the intense pressure to run with time to achieve the “time is brain”-based goals.

Methods  The present study was a retrospective analysis of the data collected over a duration of 6 months from April 2019 to September 2019. We observed the incidence of stroke mimics among the patients for whom rapid response stroke code was activated during the study period. We also performed a logistic regression analysis to identify the clinical features which can act as strong predictors of stroke and mimics.

Results  A total of 314 stroke codes were activated of which 256 (81.5%) were stroke and 58 (18.5%) were the mimics. Functional disorders and epilepsy were the most common mimics (24.1% each). Female gender ( p = 0.04; odds ratio [OR] 2.9[1.0–8.8]), isolated impairment of consciousness ( p < 0.01; OR 4.3[1.5–12.6]), and isolated dysarthria ( p < 0.001) were the strong independent predictors for a stroke mimic. Hemiparesis was the strong independent predictor for a stroke ( p < 0.001; OR 0.0[0.0–0.1]).

Conclusion  In the present epoch of rapid response stroke management, a streamlined assessment by the emergency physicians based on the above clinical predictors may help in avoiding the misdiagnosis of a mimic as stroke.

Homonymous quadrantanopia associated with hyperosmolar hyperglycemic syndrome

We encountered a 64-year-old man with hyperosmolar hyperglycemic syndrome, having a sudden-onset homonymous right inferior quadrantanopia. This is the first documentation of such a phenomenon in hyperosmolar hyperglycemic syndrome. We believe this is a variant of hemianopia in patients with hyperglycemic hyperosmolar syndrome.

Metabolic Stroke: A Novel Presentation in a Child with Succinic Semialdehyde Dehydrogenase Deficiency

Succinic semialdehyde dehydrogenase (SSADH) deficiency is an autosomal recessive disorder of gamma-aminobutyric acid metabolism. Children with SSADH deficiency usually manifest with developmental delay, behavioral symptoms, language dysfunction, seizures, hypotonia, extrapyramidal symptoms, and ataxia. Diagnosis of SSADH deficiency is established by an abnormal urine organic acid pattern, including increased excretion of 4-hydroxybutyric acid and the identification of biallelic pathogenic variants in aldehyde dehydrogenase 5 family, member A 1 (ALDH5A1) gene. Here, we describe a 15-month-old girl with SSADH deficiency presenting with developmental delay, language deficits, and acute-onset right hemiparesis, following recovery from a diarrheal illness. Brain magnetic resonance imaging revealed hyperintense signal changes involving the left globus pallidus in T2-weighted images with restriction of diffusion in the diffusion-weighted images. Increased excretion of 4-hydroxybutyric acid, threo-4,5-dihydroxyhexanoic acid lactone and erythro-4,5-dihydroxyhexanoic acid lactone was detected by urine organic acid analysis and a diagnosis of SSADH deficiency was confirmed by the identification of homozygous pathogenic variant in ALDH5A1. Stroke mimic is a novel presentation in our patient with SSADH deficiency. She was initiated on treatment with vigabatrin and has shown developmental gains with the recovery of right hemiparesis. Follow-up neuroimaging shows near complete resolution of signal changes in the left globus pallidus, while there was subtle hyperintensity in the right globus pallidus. The phenotypic spectrum of SSADH deficiency is widely expanding, and this disorder should be considered in the differential diagnosis of children with metabolic stroke.

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

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.

Hunting mimics and chameleons: diagnostic difficulties in atypical acute ischaemic stroke

The seemingly straightforward diagnosis of acute ischaemic stroke can be complicated by the presence of conditions presenting similarly to stroke, and atypical strokes presenting with confusing and non-classical signs. We present a diagnostic quest to disentangle the effects of a number of stroke mimics from those of an underlying bilateral cerebrovascular phenomena, where with appropriate treatment of the non-stroke conditions the patient was able to make a near complete neurological recovery.

Misdiagnosis of stroke

Rapid diagnosis of stroke is necessary for the timely delivery of thrombolysis and evaluation of novel therapies such as neuroprotection. An accurate clinical history and competent examination are key to identifying which patients are likely to have had a stroke and arranging and interpreting neuroimaging. Stroke symptoms are typically acute in onset, but are highly variable depending on the vascular territory affected. Common presenting symptoms are limb weakness, and speech and visual disturbances. Common stroke mimics are seizures, space occupying lesions, syncope, somatization and delirium secondary to sepsis. Stroke recognition instruments can help nonspecialists in the early diagnosis of stroke, with studies reporting sensitivity of over 90% and specificity of approximately 85% for some instruments. In patients with a clinical diagnosis of stroke, brain computed tomography or MRI is required to exclude some stroke mimics and differentiate ischemic from hemorrhagic stroke, which is key to providing appropriate therapies such as thrombolysis. In the future, plasma biomarkers may improve clinical diagnosis of stroke, but prospective studies are required to establish their utility. Clinical trials of acute stroke therapies need to ensure rapid accurate diagnosis of stroke using structured clinical assessments and appropriate imaging to achieve early treatment and avoid entry of stroke mimics into trials.

Hypoglycemic encephalopathy: a case series and literature review on outcome determination

Data on clinical long-term outcome after the acute phase of hypoglycemic encephalopathy (HE) using validated outcome scales is currently unavailable. Here we report the results of a systematic literature search for studies on HE and data on long-term outcome in patients with HE admitted to three Charité hospitals between January 2005 and July 2010. HE was defined as coma/stupor and blood glucose levels <50 mg/dl on admission, persistence of coma/stupor for ≥24 h despite normalization of blood glucose levels, and exclusion of any other cause of coma/stupor. Outcome was assessed using the modified Rankin scale (mRS), Glasgow Outcome Scale (GOS), and Barthel index (BI). Fifteen patients were included, with a mean age of 60 years (range 29-79). Two were lost to follow-up. Of the remaining 13 patients, six had died (46 %). In the seven survivors, the median mRS score was 0 (range 0-5), median GOS score was 5 (range 2-5), and median BI was 100 (range 0-100). MRIs made in the acute phase were available for three patients and revealed no obvious relation between lesion size or pattern and clinical outcome. To our knowledge, this is the first case series using validated clinical scoring systems to determine clinical long-term outcome after HE. The results suggest that mortality is high, but long-term survival with little or no disability is possible and can be observed in the majority of survivors. Risk of death or poor outcome does not seem to be related to MRI features in the acute phase but rather to other presumably medical factors.

Stroke mimics and chameleons

The diagnosis of acute stroke remains a clinical diagnosis in the initial phases of patient evaluation. There is a differential diagnostic process to the abrupt onset of focal neurologic deficit that characterizes an acute stroke. "Is this a CNS event?" might be the initial question posed by the clinician. The stroke mimics of systemic problems such as hypoglycemia, hyperglycemia, and other encephalopathies are considered. Certainly consideration of hypoglycemia, which is common, easily detectable, and correctable, should occur in every stroke patient encounter. Any witnesses that suggest a convulsive episode should raise suspicion of the presence of an ictal or postictal phenomena. Next, if a CNS event is believed to exist, the different stroke subtypes are considered along with other CNS events that may simulate stroke. The standard acute neuroimaging with noncontrast CT scanning uncovers some mass lesions mimicking stroke and confirm a stroke subtype in other patients. Ischemic stroke, like other common diseases, does have uncommon manifestations. Acute stroke is considered in neurologic syndromes in which abrupt onset of symptoms figure prominently, particularly in patients with cerebrovascular risk factors.

Hypoglycemia in children with insulin-dependent diabetes mellitus

The promotion of normal growth and development and the avoidance of acute and long-term complications are overall goals in the management of a child with insulin-dependent diabetes mellitus. Recent studies provide new and pertinent information about the acute effects of hypoglycemia on such cognitive functioning as learning, memory, reading, and visuospatial skills. The effects of early onset diabetes on school performance are also discussed. This information should be incorporated by diabetes educators into the educational plan for children with IDDM, their families, and schools.