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Tang W, Sulit D, Zafar M, Abouibrahim M, Paracha A, Berliti S, Wiggins F, Sathiskumar P. A Stroke Mimic With Postictal Todd's Paresis and a Simplified Guide to Management of Acute Hyponatremia. Cureus 2023; 15:e44626. [PMID: 37799256 PMCID: PMC10548162 DOI: 10.7759/cureus.44626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2023] [Indexed: 10/07/2023] Open
Abstract
Stroke mimics typically involve non-vascular disease processes, accounting for approximately half of hospital admissions for suspected stroke. These mimics may manifest as functional (conversion) disorders or indicate other neurological or medical conditions, including hypoglycemia, brain tumors, toxic poisoning, migraines, sepsis, seizures, and electrolyte imbalances, which can imitate stroke symptoms, making the diagnosis complex. In this report, we present a unique case of a man in his sixties who developed acute postoperative hyponatremia, an electrolyte abnormality frequently encountered but rarely presented with focal neurological deficits. This condition resulted in facial asymmetry and hemiparesis; however, the remarkable outcome was that these deficits were completely resolved once the hyponatremia was corrected.
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Affiliation(s)
- Wenxi Tang
- Internal Medicine, Conquest Hospital, East Sussex Healthcare National Health Services (NHS) Trust, Hastings, GBR
| | - Dina Sulit
- Internal Medicine, Conquest Hospital, East Sussex Healthcare National Health Services (NHS) Trust, Hastings, GBR
| | - Mansoor Zafar
- Gastroenterology, Hammersmith & Charing Cross Hospitals, Imperial College London Healthcare National Health Services (NHS) Trust, London, GBR
| | - Mahmoud Abouibrahim
- Internal Medicine, Conquest Hospital, East Sussex Healthcare National Health Services (NHS) Trust, Hastings, GBR
| | - Abdul Paracha
- Internal Medicine, Conquest Hospital, East Sussex Healthcare National Health Services (NHS) Trust, Hastings, GBR
| | - Stefano Berliti
- Acute Medicine, Conquest Hospital, East Sussex Healthcare National Health Services (NHS) Trust, Hastings, GBR
| | - Fraser Wiggins
- Anaesthesiology, Conquest Hospital, East Sussex Healthcare National Health Services (NHS) Trust, Hastings, GBR
| | - Periasamy Sathiskumar
- Diabetes and Endocrinology, Conquest Hospital, East Sussex Healthcare National Health Services (NHS) Trust, Hastings, GBR
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2
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Khalili N, Wang R, Garg T, Ahmed A, Hoseinyazdi M, Sair HI, Luna LP, Intrapiromkul J, Deng F, Yedavalli V. Clinical application of brain perfusion imaging in detecting stroke mimics: A review. J Neuroimaging 2023; 33:44-57. [PMID: 36207276 DOI: 10.1111/jon.13061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 02/01/2023] Open
Abstract
Stroke mimics constitute a significant proportion of patients with suspected acute ischemic stroke. These conditions may resemble acute ischemic stroke and demonstrate abnormalities on perfusion imaging sequences. The most common stroke mimics include seizure/epilepsy, migraine with aura, brain tumors, functional disorders, infectious encephalopathies, Wernicke's encephalopathy, and metabolic abnormalities. Brain perfusion imaging techniques, particularly computed tomography perfusion and magnetic resonance perfusion, are being widely used in routine clinical practice for treatment selection in patients presenting with large vessel occlusion. At the same time, the utilization of these imaging modalities enables the opportunity to better diagnose patients with stroke mimics in a time-sensitive setting, leading to appropriate management, decision-making, and resource allocation. In this review, we describe patterns of perfusion abnormalities that could discriminate patients with stroke mimics from those with acute ischemic stroke and provide specific case examples to illustrate these perfusion abnormalities. In addition, we discuss the challenges associated with interpretation of perfusion images in stroke-related pathologies. In general, perfusion imaging can provide additional information in some cases-when used in combination with conventional magnetic resonance imaging and computed tomography-and might help in detecting stroke mimics among patients who present with acute onset focal neurological symptoms.
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Affiliation(s)
- Neda Khalili
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Richard Wang
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Tushar Garg
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Amara Ahmed
- Department of Radiology, Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Meisam Hoseinyazdi
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Haris I Sair
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Licia P Luna
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jarunee Intrapiromkul
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Francis Deng
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
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3
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Wood RM, Moss SJ, Murch BJ, Vasilakis C, Clatworthy PL. Optimising acute stroke pathways through flexible use of bed capacity: a computer modelling study. BMC Health Serv Res 2022; 22:1068. [PMID: 35987642 PMCID: PMC9392305 DOI: 10.1186/s12913-022-08433-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/10/2022] [Indexed: 11/11/2022] Open
Abstract
Background Optimising capacity along clinical pathways is essential to avoid severe hospital pressure and help ensure best patient outcomes and financial sustainability. Yet, typical approaches, using only average arrival rate and average lengths of stay, are known to underestimate the number of beds required. This study investigates the extent to which averages-based estimates can be complemented by a robust assessment of additional ‘flex capacity’ requirements, to be used at times of peak demand. Methods The setting was a major one million resident healthcare system in England, moving towards a centralised stroke pathway. A computer simulation was developed for modelling patient flow along the proposed stroke pathway, accounting for variability in patient arrivals, lengths of stay, and the time taken for transfer processes. The primary outcome measure was flex capacity utilisation over the simulation period. Results For the hyper-acute, acute, and rehabilitation units respectively, flex capacities of 45%, 45%, and 36% above the averages-based calculation would be required to ensure that only 1% of stroke presentations find the hyper-acute unit full and have to wait. For each unit some amount of flex capacity would be required approximately 30%, 20%, and 18% of the time respectively. Conclusions This study demonstrates the importance of appropriately capturing variability within capacity plans, and provides a practical and economical approach which can complement commonly-used averages-based methods. Results of this study have directly informed the healthcare system’s new configuration of stroke services.
Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08433-0.
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Allen M, Pearn K, Ford GA, White P, Rudd AG, McMeekin P, Stein K, James M. National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study. Eur Stroke J 2021; 7:28-40. [PMID: 35300255 PMCID: PMC8921787 DOI: 10.1177/23969873211063323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives To guide policy when planning thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship’ (secondary transfer) provision and the impact of bypassing local acute stroke centres. Design Outcome-based modelling study. Setting 107 acute stroke centres in England, 24 of which provide IVT and MT (IVT/MT centres) and 83 provide only IVT (IVT-only units). Participants 242,874 emergency admissions with acute stroke over 3 years (2015–2017). Intervention Reperfusion delivered by drip-and-ship, mothership or ‘hybrid’ models; impact of additional travel time to directly access an IVT/MT centre by bypassing a more local IVT-only unit; effect of pre-hospital selection for large artery occlusion (LAO). Main outcome measures Population benefit from reperfusion, time to IVT and MT, admission numbers to IVT-only units and IVT/MT centres. Results Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit, assuming unknown patient status, accrues from direct conveyance to an IVT/MT centre. However, this policy produces unsustainable admission numbers at these centres, with 78 out of 83 IVT-only units receiving fewer than 300 admissions per year (compared to 3 with drip-and-ship). Implementing a maximum permitted additional travel time to bypass an IVT-only unit, using a pre-hospital test for LAO, and selecting patients based on stroke onset time, all help to mitigate the destabilising effect but there is still some significant disruption to admission numbers, and improved selection of patients suitable for MT selectively reduces the number of patients who would receive IVT at IVT-only centres, challenging the sustainability of IVT expertise in IVT-only centres. Conclusions Implementation of reperfusion for acute stroke based solely on achieving the maximum population benefit potentially leads to destabilisation of the emergency stroke care system. Careful planning is required to create a sustainable system, and modelling may be used to help planners maximise benefit from reperfusion while creating a sustainable emergency stroke care system.
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Affiliation(s)
- Michael Allen
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Kerry Pearn
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Gary A Ford
- Radcliffe Department of Medicine, Oxford University and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil White
- Translational and Clinical Research Institute, Newcastle University and Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Anthony G Rudd
- Kings College London and Guy’s and St Thomas, NHS Foundation Trust, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Ken Stein
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Martin James
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Barra M, Faiz KW, Dahl FA, Næss H. Stroke Mimics on the Stroke Unit - Temporal trends 2008-2017 at a large Norwegian university hospital. Acta Neurol Scand 2021; 144:695-705. [PMID: 34498731 DOI: 10.1111/ane.13527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/11/2021] [Accepted: 08/19/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective was to quantify temporal trends in stroke mimics (SM) admissions relative to cerebrovascular accidents (CVA), incidence of hospitalized SMs and characterize the SM case-mix at a general hospital's stroke unit (SU). MATERIALS & METHODS All SU admissions (n = 11240) of patients aged 15 or older to Haukeland University Hospital between 2008-2017 were prospectively included and categorized as CVA or SM. Logistic regression was used to estimate time trends in the proportion of SMs among the admissions. Poisson regression was used to estimate time trends in age- and sex-dependent SM incidence. RESULTS SMs were on average younger thaan CVA patients (68.3 vs. 71.4 years) and had a higher proportion of females (53.6% vs. 44.5%). The total proportion of SM admissions was 51.0%. There was an increasing time trend in the proportion of SM admissions, odds ratio 1.150 per year (p < 0.001), but this trend appears flattening, represented by a significant quadratic time-term, odds ratio 1.009 (p < 0.001). A higher SM proportion was also associated with the time period of a Mass Media Intervention (FAST campaign) in 2014. There was also an increasing trend in SM incidence, that remains after adjusting for age, sex, and population; also, for incidence the trend appears to be flattening. CONCLUSIONS SMs account for approximately half of the SU admissions, and the proportion has been increasing. A FAST campaign appears to have temporarily increased the SM proportion. The age- and sex-dependent incidence of SM has been increasing but appears to flatten out.
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Affiliation(s)
- Mathias Barra
- The Health Services Research Unit (HØKH) Akershus University Hospital HF Lørenskog Norway
- Institute for Global Health BCEPSUniversity of Bergen Bergen Norway
| | - Kashif Waqar Faiz
- The Health Services Research Unit (HØKH) Akershus University Hospital HF Lørenskog Norway
- Department of Neurology Akershus University Hospital HF Lørenskog Norway
| | - Fredrik Andreas Dahl
- The Health Services Research Unit (HØKH) Akershus University Hospital HF Lørenskog Norway
| | - Halvor Næss
- Department of Neurology Haukeland University Hospital HF Bergen Norway
- Centre for age‐related medicine Stavanger University Hospital Stavanger Norway
- Institute of clinical medicine University of Bergen Bergen Norway
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Mangiardi M, Anticoli S, Bertaccini L, Cozzolino V, Pezzella FR. Acute Onset Focal Epilepsy Mimicking Stroke. Cureus 2021; 13:e18600. [PMID: 34786219 PMCID: PMC8577821 DOI: 10.7759/cureus.18600] [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] [Accepted: 10/08/2021] [Indexed: 11/17/2022] Open
Abstract
A wide range of acute neurological disorders may present with symptoms similar to a stroke, so-called 'stroke mimics'. Migraine aura and seizures account for the most extensive stroke mimics population. A large number of patients with a definite stroke mimics diagnosis (most commonly those with psychiatric disorders or seizures) had been treated with IV alteplase without adverse related events. We report a case of a man aged 70 years admitted to the emergency room because of acute onset of delirium and a loss of strength in the left arm (National Institutes of Health Stroke Scale {NIHSS}: 10), severe hyponatremia (127 mEq/L), and no evidence of intracranial arterial occlusion at CT scan. He was eligible for intravenous thrombolysis and, after treatment, neurological symptoms improved (NIHSS: 2). The subsequent appearance of “clonus” in the left lower limb, the persistence of hyponatremia, and the presence of electroencephalogram (EEG) abnormalities led to the clinical suspicion of focal motor-onset seizure with impaired awareness. The patient was treated successfully with anti-seizure medications (ASMs): lacosamide 200 mg IV during the acute setting care, followed by oral lacosamide 200 mg bis in die (BID). Since two other focal seizures occurred, brivaracetam 25 mg BID has been added in therapy with subsequent clinical discontinuance and EEG normalization. Two consecutive magnetic resonance imaging (MRI) examinations showed several cortical lesions restricted in high signal in diffusion‐weighted imaging (DWI) which corresponding to T2‐weighted and fluid‐attenuated inversion recovery (FLAIR) hyperintensities, but without lesions evidence in apparent diffusion coefficient (ADC) map. These radiological changes disappeared at a follow-up MRI performed 20 days after the symptoms’ onset. The patient fully recovered was discharged home without developing pharmacological adverse events. In this case, MRI provided an opportunity for early identification of seizure-related alterations. Hence, we discuss how prospective MRI studies during seizures and interictal period would contribute to defining the relationship between the electroclinical characteristics and MRI alteration patterns, and therefore, the potential role of MRI in the differential diagnosis between seizures and stroke mimic.
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Affiliation(s)
| | - Sabrina Anticoli
- Stroke Unit, Azienda Ospedaliera San Camillo Forlanini, Rome, ITA
| | - Luca Bertaccini
- Neuroradiology, Azienda Ospedaliera San Camillo Forlanini, Rome, ITA
| | - Valeria Cozzolino
- Neuroradiology, Azienda Ospedaliera San Camillo Forlanini, Rome, ITA
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Pohl M, Hesszenberger D, Kapus K, Meszaros J, Feher A, Varadi I, Pusch G, Fejes E, Tibold A, Feher G. Ischemic stroke mimics: A comprehensive review. J Clin Neurosci 2021; 93:174-182. [PMID: 34656244 DOI: 10.1016/j.jocn.2021.09.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/01/2021] [Accepted: 09/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Ischemic stroke is the leading cause of disability and one of the leading causes of death. Ischemic stroke mimics (SMs) can account for a noteble number of diagnosed acute strokes and even can be thrombolyzed. METHODS The aim of our comprehensive review was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of SMs in stroke/thrombolysis situations. RESULTS Overall, 61 studies were selected with 62.664 participants. Ischemic stroke mimic rate was 24.8% (15044/60703). Most common types included peripheral vestibular dysfunction in 23.2%, toxic/metabolic in 13.2%, seizure in 13%, functional disorder in 9.7% and migraine in 7.76%. Ischemic stroke mimic have less vascular risk factors, younger age, female predominance, lower (nearly normal) blood pressure, no or less severe symptoms compared to ischemic stroke patients (p < 0.05 in all cases). 61.7% of ischemic stroke patients were thrombolysed vs. 26.3% among SMs (p < 0.001). (p < 0.001). Overall intracranial hemorrhage was reported in 9.4% of stroke vs. 0.7% in SM patients (p < 0.001). Death occurred in 11.3% of stroke vs 1.9% of SM patients (p < 0.001). Excellent outcome was (mRS 0-1) was reported in 41.8% ischemic stroke patients vs. 68.9% SMs (p < 0.001). Apart from HINTS manouvre or Hoover sign there is no specific method in the identification of mimics. MRI DWI or perfusion imaging have a role in the setup of differential diagnosis, but merit further investigation. CONCLUSION Our article is among the first complex reviews focusing on ischemic stroke mimics. Although it underscores the safety of thrombolysis in this situation, but also draws attention to the need of patient evaluation by physicians experienced in the diagnosis of both ischemic stroke and SMs, especially in vertigo, headache, seizure and conversional disorders.
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Affiliation(s)
- Marietta Pohl
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | | | - Krisztian Kapus
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Janos Meszaros
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | | | - Imre Varadi
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | | | | | - Antal Tibold
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Gergely Feher
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary; Neurology Outpatient Clinic, EÜ-MED KFT, Komló, Hungary.
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8
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Malinovic M, Peterson J, Lee F. Pneumococcal meningitis complicated by otomastoiditis and pneumocephalus confounding an acute ischemic stroke diagnosis. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.210003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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9
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Kanagaratnam M, Boodhoo A, MacDonald BK, Nitkunan A. Prevalence of acute neurology: a 2-week snapshot in a district general hospital. Clin Med (Lond) 2021; 20:169-173. [PMID: 32188653 DOI: 10.7861/clinmed.2019-0377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Neurological illnesses are a common cause of hospital admissions, yet most patients are not primarily managed by neurologists. Acute neurology service provision varies across the UK. This study aimed to establish the number of neurological admissions during a 2-week period in a district general hospital, as well as the proportion of those patients who were seen by the hyperacute neurology team. This was done by analysing the diagnostic codes. It was established that there was a total of 2,242 admissions during the study period and, of those, 491 (22%) had neurological codes. Analysis of the 491 hospital electronic records revealed that 229 (10%) were truly neurologically relevant and, of those, 14% of patients received an opinion from the neurology team. Therefore, it can be concluded that only a small proportion of acute neurology is currently being seen by neurologists.
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10
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Sammut-Powell C, Ashton C, Paroutoglou K, Parry-Jones A. Differences in Characteristics and Ambulance Pathway Adherence Between Strokes and Mimics Presenting to a Large UK Centralized Hyper Acute Stroke Unit (HASU). Front Neurol 2021; 12:646015. [PMID: 34040576 PMCID: PMC8143189 DOI: 10.3389/fneur.2021.646015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/08/2021] [Indexed: 12/02/2022] Open
Abstract
Background: In Greater Manchester (GM), prehospital clinicians use the Face Arm Speech Test (FAST) to identify suspected stroke patients alongside pathway exclusions. Within the centralized stroke service, patients with a suspected stroke are taken directly to a Hyper Acute Stroke Unit (HASU), often bypassing their local emergency department (ED). However, many of these patients are experiencing an illness that looks like a stroke but is not a stroke. The data collected in the prehospital setting is rarely used in research yet could give valuable insights into the performance of the pathway. Aim: To evaluate the presenting symptoms and final diagnoses of prehospital suspected strokes and to evaluate the adherence of prehospital stroke pathway exclusions. Methods: We analyzed data from all patients brought in by ambulance and admitted on the stroke pathway between 01/09/15 and 28/02/17. Patient demographics and all data recorded in the prehospital setting were evaluated to identify differences in stroke, TIA, and mimic patients. Pathway adherence was assessed according to whether the patient was local or out-of-area (OOA) and bypassed their local ED. Results: A total of 4,216 suspected strokes were identified: 2,213 (52.5%) had a final diagnosis of stroke, 492 (11.7%) experienced a transient ischemic attack (TIA), and 1,511 (35.8%) were stroke mimics. There were 714 (16.9%) patients that were identified as having at least one pathway exclusion or were FAST negative, of which 270 (37.8%) experienced a stroke. The proportion of strokes was significantly lower in those with a pathway exclusion (41.8 vs. 53.5%; p < 0.001) and the proportion of breaches tended to be comparable or higher in the local population. Discussion: There are high volumes of stroke mimics but identified differences indicate there is an opportunity to better utilize prehospital data. Ambulance clinicians were able to correctly overrule FAST negative results and the volume of these suggest that FAST alone may be too restrictive.
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Affiliation(s)
- Camilla Sammut-Powell
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Christopher Ashton
- Salford Royal NHS Foundation Trust, Greater Manchester Integrated Stroke Delivery Network, Salford, United Kingdom
| | | | - Adrian Parry-Jones
- Salford Royal NHS Foundation Trust, Salford, United Kingdom.,Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, United Kingdom.,Division of Cardiovascular Science, Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
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11
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Abstract
Multimodal MR imaging provides valuable information in the management of patients with acute ischemic stroke (AIS), with diagnostic, therapeutic, and prognostic implications. MR imaging plays a critical role in treatment decision making for (1) thrombolytic treatment of AIS patients with unknown symptom-onset and (2) endovascular treatment of patients with large vessel occlusion presenting beyond 6 hours from the symptom onset. MR imaging provides the most accurate information for detection of ischemic brain and is invaluable for differentiating AIS from stroke mimics.
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12
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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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13
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Jones A, O'Connell N, David AS, Chalder T. Functional Stroke Symptoms: A Narrative Review and Conceptual Model. J Neuropsychiatry Clin Neurosci 2020; 32:14-23. [PMID: 31726918 DOI: 10.1176/appi.neuropsych.19030075] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Stroke services have been reconfigured in recent years to facilitate early intervention. Throughout stroke settings, some patients present with functional symptoms that cannot be attributed to a structural cause. Emphasis on fast diagnosis and treatment means that a proportion of patients entering the care pathway present with functional symptoms that mimic stroke or have functional symptoms in addition to vascular stroke. There is limited understanding of mechanisms underlying functional stroke symptoms, how the treatment of such patients should be managed, and no referral pathway or treatment. Predisposing factors vary between individuals, and symptoms are heterogeneous: onset can be acute or insidious, and duration can be short-lived or chronic in the context of new or recurrent illness cognitions and behaviors. This article proposes a conceptual model of functional symptoms identified in stroke services and some hypotheses based on a narrative review of the functional neurological disorder literature. Predisposing factors may include illness experiences, stressors, and chronic autonomic nervous system arousal. Following the onset of distressing symptoms, perpetuating factors may include implicit cognitive processes, classical and operant conditioning, illness beliefs, and behavioral responses, which could form the basis of treatment targets. The proposed model will inform the development of theory-based interventions as well as a functional stroke care pathway.
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Affiliation(s)
- Abbeygail Jones
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
| | - Nicola O'Connell
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
| | - Anthony S David
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
| | - Trudie Chalder
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
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14
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Ifergan H, Amelot A, Ismail M, Gaudron M, Cottier JP, Narata AP. Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:88-95. [PMID: 32159722 DOI: 10.1590/0004-282x20190154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/18/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND A larger therapeutic window for stroke treatment requires a significant change in the organization of emergency services, avoiding the increase in number of imaging exams and indirectly the time to treatment. OBJECTIVE To highlight the relation between faster clinical evaluation and stroke over-suspicion and consequently excessive imaging acquisition. To identify predictors of ischemic stroke and stroke mimics (SM), aiming for better patient selection for comprehensive neuroimaging and reperfusion therapies. METHODS Retrospective, cohort, observational, single-center study that reviewed all consecutive files of patients presenting with acute neurological symptoms who underwent CT scan or MRI from July 1, 2016 to July 1, 2017. RESULTS 736 patient files were reviewed. 385 patients (52.3%) presented with confirmed acute ischemic infarct, 93 (12.6%) had another brain lesion mimicking acute ischemia, and 258 (35.1%) had normal imaging. Acute stroke was more frequent in elderly patients with atrial fibrillation, arterial hypertension, or dysarthria or right motor impairment. Stroke mimic was associated with female patients with low vascular risk factors, low NIHSS, and patients with decreased level of consciousness or symptoms suggestive of posterior circulation. DISCUSSION 47.7% of all patients seen at the stroke unit did not have acute stroke lesions. Clinical assessment data have been used to provide indicators of acute stroke and stroke mimic patients, and symptoms corresponding to acute stroke and stroke mimic seem to be similar in the literature. CONCLUSION Considering that the number of patients admitted for stroke treatment will increase even further with a larger therapeutic window for mechanical thrombectomy and for thrombolysis, a diagnostic decision-making algorithm for stroke patients is required in order to reinforce the suspicion of stroke indicating an urgent MRI.
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Affiliation(s)
- Héloïse Ifergan
- Service de neuroradiologie diagnostique et interventionnelle, Centre Hospitalier Régional et Universitaire de Tours, France
| | - Aymeric Amelot
- Service de neurochirurgie, Centre Hospitalier Régional et Universitaire de Tours, France
| | - Mohammad Ismail
- Service de neuroradiologie diagnostique et interventionnelle, Centre Hospitalier Régional et Universitaire de Tours, France
| | - Marie Gaudron
- Service de neurologie vasculaire, Centre Hospitalier Régional et Universitaire de Tours, France
| | - Jean-Philippe Cottier
- Service de neuroradiologie diagnostique et interventionnelle, Centre Hospitalier Régional et Universitaire de Tours, France
| | - Ana Paula Narata
- Service de neuroradiologie diagnostique et interventionnelle, Centre Hospitalier Régional et Universitaire de Tours, France
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15
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Aben HP, Luijten L, Jansen BPW, Visser-Meily JMA, Spikman JM, Biessels GJ, de Kort PLM. Absence of an infarct on MRI is not uncommon after clinical diagnosis of ischemic stroke. J Stroke Cerebrovasc Dis 2020; 29:104979. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/04/2020] [Accepted: 05/17/2020] [Indexed: 11/16/2022] Open
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Belani P, Kihira S, Pacheco F, Pawha P, Cruciata G, Nael K. Addition of arterial spin-labelled MR perfusion to conventional brain MRI: clinical experience in a retrospective cohort study. BMJ Open 2020; 10:e036785. [PMID: 32532776 PMCID: PMC7295400 DOI: 10.1136/bmjopen-2020-036785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE The usage of arterial spin labelling (ASL) perfusion has exponentially increased due to improved and faster acquisition time and ease of postprocessing. We aimed to report potential additional findings obtained by adding ASL to routine unenhanced brain MRI for patients being scanned in a hospital setting for various neurological indications. DESIGN Retrospective. SETTING Large tertiary hospital. PARTICIPANTS 676 patients. PRIMARY OUTCOME Additional findings from ASL sequence compared with conventional MRI. RESULTS Our patient cohorts consisted of 676 patients with 257 with acute infarcts and 419 without an infarct. Additional findings from ASL were observed in 13.9% (94/676) of patients. In the non-infarct group, additional findings from ASL were observed in 7.4% (31/419) of patients, whereas in patients with an acute infarct, supplemental information was obtained in 24.5% (63/257) of patients. CONCLUSION The addition of an ASL sequence to routine brain MRI in a hospital setting provides additional findings compared with conventional brain MRI in about 7.4% of patients with additional supplementary information in 24.5% of patients with acute infarct.
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Affiliation(s)
- Puneet Belani
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shingo Kihira
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Felipe Pacheco
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Puneet Pawha
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Giuseppe Cruciata
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kambiz Nael
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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Abstract
INTRODUCTION Stroke is a significant underlying cause of epilepsy. Seizures due to ischemic stroke (IS) are generally categorized into early seizures (ESs) and late seizures (LSs). Seizures in thrombolysis situations may raise the possibility of other etiology than IS. AIM We overtook a systematic review focusing on the pathogenesis, prevalence, risk factors, detection, management, and clinical outcome of ESs in IS and in stroke/thrombolysis situations. We also collected articles focusing on the association of recombinant tissue-type plasminogen activator (rt-PA) treatment and epileptic seizures. RESULTS We have identified 37 studies with 36,775 participants. ES rate was 3.8% overall in patients with IS with geographical differences. Cortical involvement, severe stroke, hemorrhagic transformation, age (<65 years), large lesion, and atrial fibrillation were the most important risk factors. Sixty-one percent of ESs were partial and 39% were general. Status epilepticus (SE) occurred in 16.3%. 73.6% had an onset within 24 h and 40% may present at the onset of stroke syndrome. Based on EEG findings seizure-like activity could be detected only in approximately 18% of ES patients. MRI diffusion-weighted imaging and multimodal brain imaging may help in the differentiation of ischemia vs. seizure. There are no specific recommendations with regard to the treatment of ES. CONCLUSION ESs are rare complications of acute stroke with substantial burden. A significant proportion can be presented at the onset of stroke requiring an extensive diagnostic workup.
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Mathern R, Calestino M. An unusual presentation of hemiparesis: Rapidly progressing Streptococcal pneumoniae meningitis secondary to acute mastoiditis. IDCases 2020; 21:e00831. [PMID: 32477872 PMCID: PMC7251761 DOI: 10.1016/j.idcr.2020.e00831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 05/15/2020] [Accepted: 05/15/2020] [Indexed: 12/04/2022] Open
Abstract
Acute bacterial meningitis should be included in the differential diagnosis when considering stroke mimics. Potential for rapid progression highlights the importance of hourly neurological exams and early intervention. Antimicrobials, steroids, and myringotomy with tympanostomy tube are effective interventions in treating meningitis secondary to mastoiditis.
A sixty-three year-old male who arrived to our emergency department with signs and symptoms of an acute left middle cerebral artery cerebrovascular accident. Initial neurovascular imaging failed to demonstrate any abnormalities that explained his symptoms. His neurologic status rapidly deteriorated in conjunction with the development of severe sepsis. The patient required endotracheal intubation and was transferred to our intensive care unit. After an extensive diagnostic work-up, the etiology of his condition was determined to be due to bacterial meningitis originating from acute mastoiditis. Cultures of cerebrospinal fluid and peripheral blood grew Streptococcus pneumoniae. The patient improved with intravenous antimicrobials, intravenous dexamethasone and a left sided myringotomy with tympanostomy tube. The patient made a complete neurological recovery following this treatment.
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19
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Hassing LT, Verschoof MA, Koppen H. Alcohol Intoxication as a Stroke Mimic and the Incidence of Acute Alcohol Intoxication in Stroke. J Stroke Cerebrovasc Dis 2019; 28:104424. [PMID: 31624037 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 09/17/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND AIM Alcohol intoxication can be a posterior circulation stroke mimic as they share symptoms such as dysarthria, gait disturbances and nystagmus. We describe alcohol intoxication as a stroke mimic and the frequency of acute alcohol intoxication among stroke patients. METHODS Prospective observational single-center study (2014-2017, Haga Ziekenhuis, the Hague). In all patients older than 16 years presenting as possible acute stroke less than 6 hours of onset, blood ethanol was measured; greater than 0.1 blood alcohol concentration (BAC) was considered elevated. RESULTS In total 974 patients were included: 60 (6%) had elevated blood ethanol (mean: 1.3 BAC). In 180 of 974 patients (18%) a stroke mimic was diagnosed: 12 were due to alcohol intoxication (1% of total cohort, 7% of stroke mimic, mean ethanol level: 2.2 BAC). Half of these patients denied or downplayed their alcohol consumption. Stroke and concurrent alcohol intoxication occurred in 38 of 794 strokes (5%, mean ethanol level: 1.1 BAC). Compared to other stroke patients, these 38 patients presented more often after working hours (mean 6.38pm versus 2.23pm) and received alteplase and endovascular therapy less often (24% versus 43%, P = .018 and 3% versus 10%, P = .241, respectively). CONCLUSIONS Of all patients presenting as possible acute stroke, 6% also drank alcohol. 18% of the whole cohort was diagnosed with a stroke mimic. Acute alcohol intoxication as sole diagnosis was diagnosed in 1% of the total cohort and 7% of stroke mimics, 50% denied or downplayed their alcohol consumption. 5% of all stroke patients also drank alcohol, they were significantly less likely to receive alteplase or endovascular treatment.
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Affiliation(s)
- Laurien T Hassing
- Department of Neurology, Haga Ziekenhuis, The Hague, The Netherlands.
| | | | - Hille Koppen
- Department of Neurology, Haga Ziekenhuis, The Hague, The Netherlands
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20
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Dastmalchi YS, Oostema JA. The Yield of Multimodal Computed Tomography among Emergency Department Patients with Suspected Large Vessel Occlusion Stroke. J Stroke Cerebrovasc Dis 2019; 28:104353. [PMID: 31494013 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104353] [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] [Received: 06/17/2019] [Accepted: 08/13/2019] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Endovascular therapy (EVT) improves outcomes for appropriately selected acute ischemic stroke patients. Guidelines suggest rapid acquisition of noninvasive vascular imaging to screen suspected ischemic stroke patients for large vessel occlusion (LVO) and candidacy for EVT. We sought to quantify the yield of an LVO stroke screening process in an undifferentiated emergency department (ED) suspected stroke population as well as identify predictors of successful EVT. METHODS We identified a cohort of consecutive ED patients who received CT angiography and brain perfusion (CTA/P) imaging to determine candidacy for EVT during 2016. In keeping with the guidelines at that time, hospital protocol directed physicians to obtain CTA/P studies if time from the onset of symptoms was less than or equal to 6 hours, and the National Institute of Health Stroke Scale (NIHSS) more than or equal to 6 or if recommended by the consulting stroke neurologist. Final discharge diagnoses, EVT attempts, and successful reperfusion (TICI 2b or better) were recorded. Yield of CTA/P was compared among patients based on NIHSS and duration of symptoms. RESULTS Over a 12-month period, 406 suspected stroke patients were screened with CTA/P; 273 (67%) received a final diagnosis of ischemic stroke. Among cases screened, 53 (13%) underwent attempted EVT; 35 (9%) achieved successful reperfusion. Only 1 of 113 (1%) patients with an NIHSS less than 6 was successfully treated with EVT compared to 34 of 285 (12%) with higher NIHSS (p = 0.001). The probability of successful EVT declined with increasing symptom duration (p = 0.009 for trend). In multivariable analysis, NIHSS more than or equal to 6 was associated with successful EVT (odds ratio [OR] 4.0 [1.6 to 9.9]) but presentation within 6 hours of onset was not (OR 2.3 [0.8 to 6.7]). CONCLUSIONS EVT candidates were common among suspected stroke patients screened with CTA/P in the ED, however, patients with NIHSS less than 6 rarely received successful EVT.
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Affiliation(s)
- Yalda Serena Dastmalchi
- Department of Emergency Medicine, Michigan State University College of Human Medicine and Spectrum Health, Michigan.
| | - J Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine and Spectrum Health, Michigan.
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Keselman B, Cooray C, Vanhooren G, Bassi P, Consoli D, Nichelli P, Peeters A, Sanak D, Zini A, Wahlgren N, Ahmed N, Mazya MV. Intravenous thrombolysis in stroke mimics: results from the
SITS
International Stroke Thrombolysis Register. Eur J Neurol 2019; 26:1091-1097. [DOI: 10.1111/ene.13944] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 02/19/2019] [Indexed: 11/27/2022]
Affiliation(s)
- B. Keselman
- Department of Neurology Karolinska University Hospital and Department of Clinical Neuroscience Karolinska Institutet StockholmSweden
| | - C. Cooray
- Department of Neurology Karolinska University Hospital and Department of Clinical Neuroscience Karolinska Institutet StockholmSweden
| | - G. Vanhooren
- Department of Neurology AZ Sint‐Jan Brugge‐Oostende Brugge Belgium
| | - P. Bassi
- Neurological Department San Giuseppe Hospital Milan
| | - D. Consoli
- Department of Neurology Iazzolino Hospital Vibo Valentia
| | - P. Nichelli
- Stroke Unit Neurology Clinic Department of Neuroscience Ospedale Civile S. Agostino Estense Modena University Hospital University of Modena and Reggio Emilia Modena Italy
| | - A. Peeters
- Department of Neurology Cliniques Universitaires St‐Luc Brussels Belgium
| | - D. Sanak
- Comprehensive Stroke Centre Department of Neurology Palacký University Hospital Olomouc Czech Republic
| | - A. Zini
- Stroke Unit Neurology Clinic Department of Neuroscience Ospedale Civile S. Agostino Estense Modena University Hospital University of Modena and Reggio Emilia Modena Italy
| | - N. Wahlgren
- Department of Neurology Karolinska University Hospital and Department of Clinical Neuroscience Karolinska Institutet StockholmSweden
| | - N. Ahmed
- Department of Neurology Karolinska University Hospital and Department of Clinical Neuroscience Karolinska Institutet StockholmSweden
| | - M. V. Mazya
- Department of Neurology Karolinska University Hospital and Department of Clinical Neuroscience Karolinska Institutet StockholmSweden
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Moodley KK, Jones V, Yogarajah M, Patel B, Vivekananda U, Garcia-Reitboeck P, Samra K, Cluckie G, Foster O, Pereira AC, Nirmalananthan N. Hyperacute neurology at a regional neurosciences centre: a 1-year experience of an innovative service model. Clin Med (Lond) 2019; 19:119-126. [PMID: 30872292 PMCID: PMC6454365 DOI: 10.7861/clinmedicine.19-2-119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
St George's Hospital hyperacute neurology service (HANS) is a comprehensive, consultant-delivered service set in a teaching hospital regional neuroscience centre. The service addresses deficiencies in acute neurological care previously highlighted by the Royal College of Physicians and the Association of British Neurologists. HANS adopts a disease-agnostic approach to acute neurology, prioritising the emergency department (ED) management of both stroke and stroke mimics alike alongside proactive daily support to the acute medical unit and acute medical take. Rapid access clinics provide a means to assess ambulatory patients, providing an outlet to reduce the burden of referral from primary care to acute medicine. This paper reports the results from the first year of the service. Admission was avoided in 25% of the cases reviewed in the ED. Compared to historic data, there was a significant improvement in the length of stay for non-stroke disorders while the occupancy of stroke beds by non-stroke cases reduced by 50%. The configuration of this service is replicable in other neuroscience centres and provides a framework to reduce the barriers facing patients who present with acute neurological symptoms.
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Affiliation(s)
- Kuven K Moodley
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Valerie Jones
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Bhavini Patel
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | | | - Kiran Samra
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Gillian Cluckie
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Oliver Foster
- St George's University Hospitals NHS Foundation Trust, London, UK
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23
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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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The frequency, characteristics and aetiology of stroke mimic presentations: a narrative review. Eur J Emerg Med 2019; 26:2-8. [DOI: 10.1097/mej.0000000000000550] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Allen M, Pearn K, James M, Ford GA, White P, Rudd AG, McMeekin P, Stein K. Maximising access to thrombectomy services for stroke in England: A modelling study. Eur Stroke J 2018; 4:39-49. [PMID: 31165093 DOI: 10.1177/2396987318785421] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/24/2018] [Indexed: 12/11/2022] Open
Abstract
Purpose Both intravenous thrombolysis (IVT) and intra-arterial endovascular thrombectomy (ET) improve the outcome of patients with acute ischaemic stroke, with endovascular thrombectomy being an option for those patients with large vessel occlusions. We sought to understand how organisation of services affects time to treatment for both intravenous thrombolysis and endovascular thrombectomy. Method A multi-objective optimisation approach was used to explore the relationship between the number of intravenous thrombolysis and endovascular thrombectomy centres and times to treatment. The analysis is based on 238,887 emergency stroke admissions in England over 3 years (2013-2015). Results Providing hyper-acute care only in comprehensive stroke centres (CSC, providing both intravenous thrombolysis and endovascular thrombectomy, and performing >150 endovascular thrombectomy per year, maximum 40 centres) in England would lead to 15% of patients being more than 45 min away from care, and would create centres with up to 4300 stroke admissions/year. Mixing hyper-acute stroke units (providing intravenous thrombolysis only) with comprehensive stroke centres speeds time to intravenous thrombolysis and mitigates admission numbers to comprehensive stroke centres, but at the expense of increasing time to endovascular thrombectomy. With 24 comprehensive stroke centres and all remaining current acute stroke units as hyper-acute stroke units, redirecting patients directly to attend a comprehensive stroke centre by accepting a small delay (15-min maximum) in intravenous thrombolysis reduces time to endovascular thrombectomy: 25% of all patients would be redirected from hyper-acute stroke units to a comprehensive stroke centre, with an average delay in intravenous thrombolysis of 8 min, and an average improvement in time to endovascular thrombectomy of 80 min. The balance of comprehensive stroke centre:hyper-acute stroke unit admissions would change from 24:76 to 49:51. Conclusion Planning of hyper-acute stroke services is best achieved when considering all forms of acute care and ambulance protocol together. Times to treatment need to be considered alongside manageable and sustainable admission numbers.
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Affiliation(s)
- Michael Allen
- University of Exeter Medical School, Exeter, UK.,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, UK
| | - Kerry Pearn
- University of Exeter Medical School, Exeter, UK.,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, UK
| | - Martin James
- University of Exeter Medical School, Exeter, UK.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Gary A Ford
- Radcliffe Department of Medicine, Oxford University, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle-upon-Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Anthony G Rudd
- Kings College London, London, UK.,Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle-upon-Tyne, UK
| | - Ken Stein
- University of Exeter Medical School, Exeter, UK.,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, UK
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Allen M, Pearn K, Villeneuve E, Monks T, Stein K, James M. Feasibility of a hyper-acute stroke unit model of care across England: a modelling analysis. BMJ Open 2017; 7:e018143. [PMID: 29247093 PMCID: PMC5736033 DOI: 10.1136/bmjopen-2017-018143] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The policy of centralising hyperacute stroke units (HASUs) in England aims to provide stroke care in units that are both large enough to sustain expertise (>600 admissions/year) and dispersed enough to rapidly deliver time-critical treatments (<30 min maximum travel time). Currently, just over half (56%) of patients with stroke access care in such a unit. We sought to model national configurations of HASUs that would optimise both institutional size and geographical access to stroke care, to maximise the population benefit from the centralisation of stroke care. DESIGN Modelling of the effect of the national reconfiguration of stroke services. Optimal solutions were identified using a heuristic genetic algorithm. SETTING 127 acute stroke services in England, serving a population of 54 million people. PARTICIPANTS 238 887 emergency admissions with acute stroke over a 3-year period (2013-2015). INTERVENTION Modelled reconfigurations of HASUs optimised for institutional size and geographical access. MAIN OUTCOME MEASURE Travel distances and times to HASUs, proportion of patients attending a HASU with at least 600 admissions per year, and minimum and maximum HASU admissions. RESULTS Solutions were identified with 75-85 HASUs with annual stroke admissions in the range of 600-2000, which achieve up to 82% of patients attending a stroke unit within 30 min estimated travel time (with at least 95% and 98% of the patients being within 45 and 60 min travel time, respectively). CONCLUSIONS The reconfiguration of hyperacute stroke services in England could lead to all patients being treated in a HASU with between 600 and 2000 admissions per year. However, the proportion of patients within 30 min of a HASU would fall from over 90% to 80%-82%.
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Affiliation(s)
- Michael Allen
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Kerry Pearn
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Emma Villeneuve
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Thomas Monks
- NIHR CLAHRC Wessex Data Science Hub, Southampton General Hospital, Southampton, UK
| | - Ken Stein
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Martin James
- Stroke Services, Royal Devon & Exeter NHS trust, Exeter, UK
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Lane R, Nisbet A. Stroke mimic diagnoses presenting to a hyperacute stroke unit. Clin Med (Lond) 2017; 17:190-191. [PMID: 28365641 PMCID: PMC6297635 DOI: 10.7861/clinmedicine.17-2-190a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Angus Nisbet
- Queen Victoria Hospital and Western Sussex Hospitals NHS Trusts, East Grinstead, UK
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28
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Jolobe OM. Stroke mimic diagnoses presenting to a hyperacute stroke unit. Clin Med (Lond) 2017; 17:95-96. [PMID: 28148593 PMCID: PMC6297582 DOI: 10.7861/clinmedicine.17-1-95a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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