Mimics and chameleons in stroke

The Burden of Stroke Mimics Among Hyperacute Stroke Unit Attendees with Special Emphasis on Migraine: A 10-Year Evaluation

BACKGROUND AND OBJECTIVES

Stroke and migraine are common neurological illnesses that cause tremendous suffering for patients. Certain diseases can mimic the clinical manifestations of an actual stroke. Migraine is one of the most commonly reported stroke mimics. The main goals of this study are to look at the prevalence of stroke mimics on the stroke pathway of Sheffield Teaching Hospitals and how many of them are migraines.

MATERIALS AND METHODS

A retrospective service evaluation was conducted at the hyperacute stroke unit (HASU) of the Royal Hallamshire Hospital (RHH) in the United Kingdom. The total admissions from 2013 to 2022 were collected from the Sentinel Stroke National Audit Programme database, and the number of stroke mimics was evaluated each year. The burden of migraine stroke mimics was also evaluated. Then, a one-year sample of stroke mimics was extracted to look for the types of each mimic.

RESULTS

From 2013 to 2022, 45.75% (n = 12156) of the stroke pathway patients (n = 26573) were stroke mimics, with an increment of up to 55% in the years 2021 and 2022. During these 10 years, migraine stroke mimics accounted for 10.21% of admissions (n = 1240). The three most common mimics in a one-year sample of stroke pathway patients were migraine (14.70%) (n = 373), functional neurological disorders (FNDs) (7.17%) (n = 182), and Guillain-Barré syndrome (6.66%) (n = 169). Seizures, syncope, and metabolic derangements were reported as mimics in 4.17% (n = 106), 3.14% (n = 80), and 1.77% (n = 45), respectively.

CONCLUSIONS

About half of the HASU attendees were stroke mimics rather than actual strokes, and the most common mimics were migraines.

Association of Circulating Circular RNAs (hg38_circ_0008980, and CircDLGAP4) in Diagnosis, Diseases Severity, and Prognosis of Ischemic Stroke

Background

Fast diagnosing ischemic stroke (IS) is a critical issue in clinical studies, as it allows more effective therapy and stops the progression of IS. The blood level of circular RNAs (CircRNAs) after stroke may be a rapid diagnostic marker.

Methods

In this study, the blood level of circRNAs was evaluated using a real-time polymerase chain reaction (PCR). We used logistic and linear regression analysis to assess the potential of circRNAs levels with the risk of IS.

Results

circRNA DLG associated protein 4 (CircDLGAP4) was decreased in patients compared with controls, and logistic regression showed its expression negatively associated with IS risk. The expression level of human genome version 38_Circular_0008980 (hg38_circ_0008980) was reduced significantly in patients with small vessel disease (SVD), and the linear regression analysis showed a negative relationship between hg38_circ_0008980 expressions with SVD subtype. hg38_circ_0008980 expression relative to controls showed a significant association with IS risk.

Conclusion

Taken together, we found a significant decrease in the level of hg38_circ_0008980 after IS; it may act as a novel circRNA in IS pathophysiology with a positive correlation with stroke severity.

A case of spinal epidural lipomatosis presenting as a stroke mimic

Here we present the case of a patient with right upper extremity and right lower extremity weakness of a three-day duration, which triggered a stroke evaluation. Ultimately, the diagnosis of spinal epidural lipomatosis (SEL) was made. Non-stroke diagnoses that present with stroke-like symptoms are referred to in the medical literature as stroke mimics. Such cases present with neurological deficits that imitate acute ischemic stroke. The frequency of such presentations occurs in up to 30% of initially suspected stroke. This case illustrates that SEL can present as a stroke mimic. To our knowledge, this is the first description of a presentation in the medical literature of SEL as a stroke mimic.

Transient unilateral weakness: is it a transient ischaemic attack?

Transient ischaemic attack is an emergency medical condition that causes brief negative focal neurological symptoms such as unilateral weakness. The symptoms herald a high risk of stroke and hence require urgent assessment. The challenge lies in the brevity and compendium of associated symptoms that can ‘mimic’ a plethora of other conditions. The result is a high rate of referrals to transient ischaemic attack clinics for these stroke mimics. This article highlights the diagnostic challenges in transient ischaemic attack with relevance to unilateral weakness.

Ischemic stroke mimics: A comprehensive review

BACKGROUND

Ischemic stroke is the leading cause of disability and one of the leading causes of death. Ischemic stroke mimics (SMs) can account for a noteble number of diagnosed acute strokes and even can be thrombolyzed.

METHODS

The aim of our comprehensive review was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of SMs in stroke/thrombolysis situations.

RESULTS

Overall, 61 studies were selected with 62.664 participants. Ischemic stroke mimic rate was 24.8% (15044/60703). Most common types included peripheral vestibular dysfunction in 23.2%, toxic/metabolic in 13.2%, seizure in 13%, functional disorder in 9.7% and migraine in 7.76%. Ischemic stroke mimic have less vascular risk factors, younger age, female predominance, lower (nearly normal) blood pressure, no or less severe symptoms compared to ischemic stroke patients (p < 0.05 in all cases). 61.7% of ischemic stroke patients were thrombolysed vs. 26.3% among SMs (p < 0.001). (p < 0.001). Overall intracranial hemorrhage was reported in 9.4% of stroke vs. 0.7% in SM patients (p < 0.001). Death occurred in 11.3% of stroke vs 1.9% of SM patients (p < 0.001). Excellent outcome was (mRS 0-1) was reported in 41.8% ischemic stroke patients vs. 68.9% SMs (p < 0.001). Apart from HINTS manouvre or Hoover sign there is no specific method in the identification of mimics. MRI DWI or perfusion imaging have a role in the setup of differential diagnosis, but merit further investigation.

CONCLUSION

Our article is among the first complex reviews focusing on ischemic stroke mimics. Although it underscores the safety of thrombolysis in this situation, but also draws attention to the need of patient evaluation by physicians experienced in the diagnosis of both ischemic stroke and SMs, especially in vertigo, headache, seizure and conversional disorders.

Glioblastoma Multiforme Masquerading as Stroke

Sudden-onset anomic aphasia is a unique symptom that is suggestive of an acute etiology. This case presents a sudden-onset focal neurological deficit with an underlying brain tumor. A 68-year-old female awoke with sudden-onset anomic aphasia, with mild hypertension as her only medical history. After an initial stroke workup was unremarkable, magnetic resonance imaging found a focal lesion on the left temporal lobe. An electroencephalogram showed lateralized periodic discharge and a focal area of increased epileptic potential in the left temporal lobe. Brain biopsy revealed World Health Organization grade IV glioblastoma, followed by resection. This case is an important reminder that chronic etiologies may present with acute symptoms.

Stroke mimic in an acute rehabilitation unit patient with associated hypomagnesaemia

This case report describes a patient who presented with acute left facial numbness and eyelid weakness prompting work-up, which demonstrated low suspicion for new stroke but revealed hypomagnesaemia as a potential differential diagnosis. Patient initially presented to the emergency department with left upper extremity weakness and was diagnosed with right basal ganglia infarction. Two weeks after transfer to the acute rehabilitation unit, patient suddenly complained of left facial numbness and eyelid weakness. However, brain imaging did not show any new acute infarct. Instead, laboratory results showed hypomagnesaemia at 1.50 mg/dL. Patient was therefore treated with intravenous magnesium leading to resolution of his symptoms. Up to 30% of acute stroke presentations are stroke mimics. Although hypomagnesaemia is less frequently seen as a mimic, its neuromuscular manifestations may present with similar symptoms. Patients will always benefit from a comprehensive evaluation for stroke symptoms, but it is important to consider the mimics as well.

Mechanical Thrombectomy for Azygos Anterior Cerebral Artery Occlusion: A Case Report and Literature Review

Objective

Azygos anterior cerebral artery (ACA) is a well-known anomaly of the second segment of the ACA. Although cases of intracerebral aneurysms related to this anomaly have been reported, acute ischemic stroke (AIS) related to the azygos ACA is extremely rare.

Case Presentation

An 84-year-old man developed disturbance of consciousness (Glasgow Coma Scale [GCS] E3V1M5), quadriparesis and aphasia, with a National Institutes of Health Stroke Scale (NIHSS) score of 32. Magnetic resonance imaging (MRI) showed no early ischemic changes, although a head magnetic resonance angiogram (MRA) demonstrated a single A2 trunk without any A3 branches that were suspected bilateral ACA occlusions. Mechanical thrombectomy for the occluded A2 trunk with contact aspiration using a Penumbra 4MAX aspiration catheter was performed, and the clot was retrieved and complete recanalization was achieved after two attempts (Thrombolysis in Cerebral Infarction scale 3) without any complications (onset to recanalization time: 187 min). The final angiogram demonstrated the recanalization of the single A2 and bilateral A3 branches, so we diagnosed as azygos ACA occlusion. MRI performed the next day revealed several small infarctions in bilateral frontal lobes, but ischemic symptoms gradually improved. NIHSS score decreased to two in 2 weeks and modified Rankin Scale (mRS) score at 90 days was one.

Conclusion

In this case, occlusion of the azygos ACA led to a large ischemic penumbra that spread widely and bilaterally in the ACA area, resulting in sudden onset of severe ischemic symptoms, including quadriparesis and aphasia. However, due to complete and rapid recanalization with contract aspiration, a large part of the ACA territory bilaterally was salvaged and the patient recovered extremely well.

Implicit bias in stroke care: A recurring old problem in the rising incidence of young stroke

Stroke is a leading cause of morbidity and mortality worldwide. Although the majority of strokes affect the elderly, the incidence of stroke in young patients is on the rise. Prompt recognition of stroke symptoms and time critical therapies play a key role in management and prognosis of this condition. This is especially critical in young stroke patients, for whom delays in early recognition and treatment can result in many years of disability with associated social and financial burden. Misdiagnosis and unwarranted variation in treatment of stroke in young patients is problematic. Clinician implicit bias, the unconscious and unintentional process of judgement in healthcare decision-making, is a contributor to the short-falls in outcomes in this population. Interventions in this process have been shown to improve clinical outcomes in young stroke patients and represent an active area of study.

Stroke Mimics and Chameleons from the Radiological Viewpoint of Glioma Diagnosis

Gliomas are sometimes difficult to differentiate from strokes and are often misdiagnosed on magnetic resonance imaging (MRI); thus, the terms “stroke mimics” and “stroke chameleons” have been introduced. In this study, we analyzed stroke mimics and stroke chameleons in glioma and discussed the diagnostic perplexity. We retrospectively reviewed cases that were removed from lesions that were considered to be brain tumors. This study enrolled 214 patients who underwent tumor resection for suspected glioma. Clinical characteristics and radiological findings of the patients were compared between the masquerade findings group, which was further divided into two groups: the stroke chameleons and stroke mimics according to their final diagnosis, and the intelligible findings group. Stroke chameleons and stroke mimics were significantly higher in age and smaller in lesion size than the intelligible findings group. In the multivariate analysis, the predictive factor of the masquerade finding group was higher age and smaller size. Stroke mimics group has a tendency to be higher rate of hyperintensity lesion on diffusion-weighted imaging (DWI) compared with stroke chameleons group. The average period from initial diagnosis to pathological diagnosis was 13.50 days in the stroke chameleons and 61.50 days in the stroke mimics, which proved significantly different. Proper diagnosis of glioma and stroke affects a patient’s prognosis, and should be diagnosed as soon as possible. However, stroke mimics and stroke chameleons caused by glioma can occur. Thus, the diagnosis of a stroke should take into consideration the possibility of a glioma in real clinical situations.

Internal carotid artery origin of the anterior cerebral artery: A rare anatomic intracranial arterial variation in a child with morning glory disc anomaly and moyamoya vascular pattern; case report and review of literature

Morning glory disc anomaly (MGDA) characterizes a congenital dysgenetic disorder of the optic disc, coexisting with arterial intracranial abnormalities, including Moyamoya vascular disease, a significantly rare disease in the European populations. We report a 2.5-year-old female child from Greece previously diagnosed with MGDA, who presented with right-hand paresis, accompanied by focal epileptic spasms, followed by an episode of brief absence seizure, as well as some arm clonic spasms. Magnetic resonance angiography scan revealed the presence of an anomalous origin of the anterior cerebral artery (ACA) from the internal carotid artery (ICA) along with vascular abnormalities, compatible with Moyamoya pattern. To the very best of our knowledge, this is the first reported case of anomalous origin of ACA from the supraclinoid ICA accompanied by severe occlusive intracranial disease (moyamoya-like pattern) in a patient with known MGDA, highlighting the embryonic character of the vascular manifestations in MGDA. It also verifies the association of Moyamoya pattern with MGDA, thus linking vascular dysgenesis as a possible cause of MGDA.

Community perceptions on the role of sexual activity on stroke: a qualitative study exploring the views of Ghanaian local community residents

BACKGROUND

Stroke is a major cause of morbidity and mortality in Ghana and sometimes comes with multifaceted complications including sexual dysfunction. While evidence is clear that living with stroke can result in sexual dysfunction, there are contradictory views regarding the causal association between sexual activity and stroke. This study explores perceptions of Ghanaian local communities on the role of sexual activity on stroke causation.

METHODS

This was a cross-sectional qualitative study. Thirty (30) focus group discussions (FGDs) were conducted in five communities across Ghana (Ga Mashie, Tafo, Gyegyeano, Chanshegu and Agorve) between October and November 2017. Data were analysed through a thematic approach.

RESULTS

Participants generally believed that sexual activity can cause a stroke. They mentioned that the dynamics through which sex can trigger a stroke include sex positions (i.e. having sex while standing and on the floor), high frequency of sex, having sex when older and engaging in indiscriminate sex.

CONCLUSION

This study shows the need to pay critical attention to these community perceptions when developing intervention strategies for stroke in Ghana. This study also highlights that discussion about sexual activity in Ghana is more complex than the current health education programme allows, and so demands a 'comprehensive sex education approach' rather than a 'disease-centered approach'.

['Stroke chameleons']

The diagnosis of acute stroke should be correct and early that allows physician planning the most effective treatment strategies (reperfusion therapy, undifferentiated (basic) treatment, early secondary prevention). However, stroke symptoms can be atypical and similar to some other (non-vascular) event. It can significantly complicate the clinical diagnosis of stroke and decrease the patient's chances for effective treatment. A stroke should be suspected in every patient with acute onset of neurological symptoms, especially when the patient has the 'vascular' risk factors. Furthermore it is important to remember that negative CT-scan data and/or MRI data do not exclude the presence of not only ischemic stroke but also hemorrhagic stroke. The article describes the main variants of strokes with atypical symptoms (strokes-chameleons), emphasizes the importance of careful clinical examination, provides supportive differential diagnostic criteria and discusses limitations of neuroimaging methods.

Neuropsychiatric symptoms as the only acute manifestation of a stroke in the left hemisphere. Case report

We report the case of a 60-year-old female patient with a history of hypertension and dyslipidemia, who suddenly presented with a clinical picture of emotional lability, disorientation, complex visual hallucinations and persecutory delusions. There were no associated neurological findings in her initial physical examination. At a local hospital she was initially diagnosed with late-onset bipolar disorder and a manic episode with psychotic features, then referred to the mental health unit, where nuclear magnetic resonance (NMR) imaging of the brain revealed an acute ischemic stroke in the territory of the left posterior cerebral artery (PCA) with haemorrhagic reperfusion to the occipital cortex. Complete and spontaneous resolution of her clinical condition was achieved after approximately 15 days.

Acute alcohol intoxication may cause delay in stroke treatment - case reports

BACKGROUND

The signs and symptoms of acute alcohol intoxication resemble those of vertebrobasilar stroke. Due to their shared symptoms including double vision, nystagmus, dysarthria, and ataxia, the differential diagnosis of alcohol intoxication and vertebrobasilar stroke may pose a challenge. Moreover, if alcohol intoxication and stroke occur simultaneously, the signs and symptoms of stroke may be attributed to the effects of alcohol, leading to delayed stroke diagnosis and failure to perform reperfusion therapy.

CASE PRESENTATIONS

Three cases of alcohol intoxication and stroke are presented. The first patient (female, 50 years old) had dysarthria, nystagmus and trunk ataxia on admission. Her blood alcohol level was 2.3‰. The symptoms improved after forced diuresis, but 5.5 h later progression was observed, and the patient developed diplopia and dysphagia in addition to her initial symptoms. Angiography showed occlusion of the basilar artery. Intraarterial thrombolysis was performed. The second patient (male, 62 years old) developed diplopia, dysarthria and trunk ataxia after consuming 4-units of alcohol, and his symptoms were attributed to alcohol intoxication. Two hours later, neurological examination revealed dysphagia and mild right-sided hemiparesis, which questioned the causal relationship between the symptoms and alcohol consumption. Cerebral CT was negative, and intravenous thrombolysis was administered. The third patient (male, 55 years old) consumed 10 units of alcohol before falling asleep. Three hours later, his relatives tried to wake him up. He was unresponsive, which was attributed to alcohol intoxication. When he woke up 8 h later, right-sided hemiparesis and aphasia were observed, and cerebral CT already revealed irreversible ischemic changes.

CONCLUSIONS

Our cases show that alcohol consumption may interfere with stroke diagnosis by mimicking the signs and symptoms of vertebrobasilar stroke. Moreover, attributing the symptoms of stroke to alcohol intoxication may delay stroke diagnosis resulting in failure of reperfusion therapy. Based on our observations we conclude that stroke should be considered in the case of worsening symptoms, dysphagia, hemiparesis and disproportionately severe signs that cannot be attributed to the amount of alcohol consumed. In the case of ambiguity, ambulance should be called, and if stroke cannot be excluded, specific therapy should be administered.

Stroke Chameleons Manifesting as Distinct Radial Neuropathies: Expertise Can Hasten the Diagnosis

Objective

Stroke chameleons encompass an atypical group of syndromes that do not initially appear to be cerebrovascular accidents. The objective of this study was to report patients with different lesions of central origin clinically presenting as wrist drop and with a semiology similar to that produced by peripheral lesions of the radial nerve at different topographical levels.

Methods

This is a case series study of patients presenting with wrist drop during the acute phase of stroke who were assessed by clinical examination and CT and MRI brain scans.

Results

Three cases presenting as monoparesis were evaluated. In all patients, the MRI revealed restricted diffusion in the pre- and post-central gyrus. Electromyography showed that the functionality of the radial, median, and ulnar nerves were intact in all three cases. The monoparesis resolved completely within 1 month of rehabilitation therapy, and no evidence of recurrent or new events was reported during the 6-month follow-up after stenting.

Conclusion

The central message of this study is that when acute onset symptoms are present in a relatively old patient with vascular risk factors, stroke should be considered as the possible aetiology until proven otherwise, and the appropriate steps should be taken to avoid a delay in the treatment and to improve outcomes.