Description of stroke mimics after complete neurovascular assessment

INTRODUCTION

A considerable percentage of events initially diagnosed as ischaemic stroke have non-cerebrovascular causes; these are called stroke mimics (SM). Currently available evidence about these events is heterogeneous and comes from studies with small samples.

OBJECTIVE

The purpose of our study is to identify conditions that may present as SM, define their epidemiological and clinical characteristics, and determine the percentage of cases of SM treated with intravenous fibrinolysis.

METHODS

Prospective study including all patients admitted to a tertiary university hospital between June 2005 and April 2015 with a diagnosis of acute stroke. We analysed demographic data, cardiovascular risk factors, time from code stroke activation to admission, stroke severity (NIHSS), final destination after discharge, degree of disability (mRS), and treatment. We compared SM and ischaemic strokes. We ruled out patients with intracranial haemorrhage, subarachnoid haemorrhage, or other causes of SM that may be detected on the baseline CT scan.

RESULTS

Four hundred four of the 4,570 included patients (8.8%) were found to have SM. Patients with SM were younger (70.3 vs. 74, P<.0001), less likely to exhibit cardiovascular risk factors and atrial fibrillation (13 vs. 34%, P<.0001), scored lower on the NIHSS at baseline (2 vs. 4, P<.0001), and included fewer cases of aphasia (9.4 vs. 19.6%, P<.02) and dysphagia (1.2 vs. 17%, P<.0001) than patients with stroke. SM caused fewer code stroke activations (28 vs. 40%, P<.0001). Patients with SM required shorter hospital stays (4.9 vs. 7.8 days, P<.0001), were less frequently admitted to the stroke unit (47 vs. 60%, P<.0001) and more frequently discharged home (95 vs. 62%, P<.0001), and had better outcomes (mRS scores 0-2; 76 vs. 54%, P<.0001). Intravenous fibrinolysis was administered to 4.7% of these patients. Epileptic seizures were the most frequent cause of SM (26%).

CONCLUSIONS

In our sample, 8.8% of all diagnoses of ischaemic stroke were SM. These events have different demographic, clinical, and prognostic characteristics; epilepsy is the most common aetiology. Despite receiving specialised emergency care, 19 patients with SM (4.7%) were treated with intravenous fibrinolysis.

Detecting in-hospital stroke: Assessment of results from a training programme for medical personnel

INTRODUCTION

In-hospital stroke (IHS) is a frequent event, but its care priority level is not well established in many hospitals. IHS care at our centre has been redefined by implementing a training programme for medical personnel not usually involved in stroke management, in order to optimise IHS detection and treatment. This study evaluates results from the training programme.

METHODS

Prospective longitudinal intervention study. Neurologists experienced in vascular diseases developed a training programme for medical personnel. We recorded incidence, epidemiological data, reason for hospitalisation, department, aetiology, severity (NIHSS), time from symptom onset to neurological assessment, use of endovascular thrombolysis, exclusion criteria for untreated patients, and 90-day outcome (mortality/disability) in 2 patient groups: patients experiencing IHS in the 6 months before (PRE) and the 6 months after the training programme (POST).

RESULTS

Sixty patients were included (19 PRE, 41 POST) with a mean age of 75.3 ± 12.5; 41% were male. There were no differences between groups regarding assessment time, treatment administered, or morbidity/mortality. Overall, 68.3% of the patients were assessed in < 4.5hours; however, only 6 patients (10%) were able to undergo endovascular therapy. This situation was mainly due to pre-existing disability (26%) and comorbidity (13%).

CONCLUSIONS

More IHS code activations were recorded after the training programme. However, that increase was not accompanied by a higher percentage of treated patients or improvements in patient prognosis during the study period, and these findings could probably be explained by the high rates of pre-existing disability and comorbidity in this series.

Predictive value of brain and vascular imaging including intracranial vessels in transient ischaemic attack patients: external validation of the ABCD3-I score

BACKGROUND AND PURPOSE

Recently, brain and vascular imaging have been added to clinical variables to identify patients with transient ischaemic attack (TIA) with a high risk of stroke recurrence. The aim of our study was to externally validate the ABCD3-I score and the same score taking into account intracranial circulation.

METHODS

We analyzed data from 1137 patients with TIA from the PROMAPA study who underwent diffusion-weighted magnetic resonance imaging (DWI) within 7 days of symptom onset. Clinical variables and diagnostic work-up were recorded prospectively. The end-points were subsequent stroke at 7 and 90 days follow-up.

RESULTS

A total of 463 (40.7%) subjects fulfilled all inclusion criteria. During follow-up, eight patients (1.7%) had a stroke within 7 days, and 14 (3.1%) had a stroke within 3 months. In the Cox proportional hazard multivariate analyses, the combination of large-artery atherosclerosis and positive DWI remained as independent predictors of stroke recurrence at 7- and 90-day follow-up [HR 8.23, 95% confidence interval (CI) 2.89-23.46, P < 0.001]. The ABCD3-I score was a powerful predictor of subsequent stroke. The area under the receiver operating characteristic curve was 0.83 (95% CI 0.72-0.93) at 7 days and 0.69 (95% CI 0.53-0.85) at 90 days. When we include intracranial vessel disease in the score, the area under the curve increases but the difference observed was non-significant.

CONCLUSION

The inclusion of vascular and neuroimaging information to clinical scales (ABCD3-I score) provides important prognostic information and also helps management decisions, although it cannot give a complete distinction between high-risk and low-risk groups.

[Reversible "man-in-the-barrel" syndrome caused by hypoxic-ischemic encephalopathy]

INTRODUCTION

Hypoxic-ischemic encephalopathy can lead to different clinical presentations, such as bilateral cortical borderzone infarctions due to cerebral hypoperfusion (especially after cardiopulmonary arrest), which would cause a "man-in-the-barrel" syndrome if the anterior circulation is affected. This syndrome has multiple etiologies, both central (bilateral frontal and/or pyramidal decussation lesions and cervical spinal cord lesions) as well as peripheral ones such as multifocal motor neuropathy.

CASE REPORT

We report the case of a 19-year-old man who developed a "man-in-the-barrel" syndrome with bilateral and proximal upper limb brachial diplegia after bilateral watershed infarctions involving distal fields of the middle and the anterior cerebral artery due to cerebral hypoperfusion in a comatose patient without internal carotid obstruction.

CONCLUSIONS

The rate of death in this syndrome is higher than 90% and it predicts a worse outcome in comatose patients. Nevertheless, our patient has had complete clinical improvement.

Monocyte count is an underlying marker of lacunar subtype of hypertensive small vessel disease

BACKGROUND

In the hypertensive small vessel disease (HSVD), it remains unclear why some patients develop lacunar infarcts (LIs) whilst others develop deep intracerebral hemorrhages (dICHs). Inflammation might be related to LI, and leukocyte and monocyte counts are regarded as an inflammatory marker of ischemic stroke.

OBJECTIVE

We investigated the relationship between leukocyte and monocyte counts determined in the first 24 h after stroke onset in HSVD patients.

METHODS

We prospectively studied 236 patients with first acute stroke because of HSVD (129 LI and 107 dICH). We analyzed demographic data, vascular risk factors, and white blood cell count subtypes obtained in the first 24 h after stroke.

RESULTS

The multivariate analysis showed that LI subtype of HSVD was correlated with hyperlipidemia (P < 0.0001), a higher monocyte count (P = 0.002), and showed a trend with current smoking (P = 0.051), whereas dICH subtype was correlated with low serum total cholesterol (P = 0.003), low serum triglycerides (P < 0.0001), and high neutrophil count (P = 0.050).

CONCLUSIONS

In patients who developed HSVD-related stroke, high monocyte count, current smoking, and hyperlipidemia are prothrombotic factors related to LI, whereas low cholesterol and triglyceride values are related to dICH. Monocyte count might be an inflammatory risk marker for the occlusion of small vessels in hypertensive patients.

Clustering of vascular risk factors and in-hospital death after acute ischemic stroke

OBJECTIVE

to evaluate the influence of clustering of vascular risk factors (VRF) on in-hospital mortality in patients with acute ischemic stroke (AIS) developing a risk score for mortality prediction.

METHODS

clinical data from 1527 patients admitted to hospital with a first-ever AIS were prospectively evaluated from 1997 to 2005 assessing the presence of six VRF: diabetes, hypertension, hyperlipidemia, ischemic heart disease, atrial fibrillation and peripheral arterial disease. A composite vascular risk score (VRS) was created using five risk factors. Hyperlipidemia was excluded from the score due to its protective impact on mortality. Two modified VRS models were created and assessed for their accuracy as predictors for in-hospital mortality based on the odds ratio for each VRF obtained in the univariate analysis.

RESULTS

197 patients (12.9 %) died during the acute hospitalization period. Stroke severity increased with each additional VRF (p = 0.002). Cox proportional hazards model adjusted for confounders showed an association between the composite VRS and in-hospital mortality (p = 0.045). According to the clustering of VRS, the risk for in-hospital death increased from 1.951 (95 % CI 1.041-3.665) for patients having one VRS to 2.343 (95% CI 1.081-5.076) for those having a VRS > or = 4. ROC curves showed that the modified VRS model based on a given value of one for each accumulated VRF, including the absence of hyperlipidemia, had the highest predictive capability for in-hospital mortality (p < 0.0001).

CONCLUSIONS

the presence of multiple VRF in patients with acute ischemic stroke increases the stroke severity and the risk of in-hospital death.

Serum lipid levels and in-hospital mortality in patients with intracerebral hemorrhage

OBJECTIVE

To test the hypothesis that low serum cholesterol and low serum triglyceride levels at admission are related to an increase of in-hospital mortality in patients with first-ever supratentorial spontaneous intracerebral hemorrhage (ICH).

METHODS

The authors obtained the serum cholesterol and triglyceride levels during the first 48 hours after first-ever ICH in 184 patients. They analyzed the impact of serum cholesterol and triglyceride concentrations on the in-hospital mortality after adjustment for possible confounding variables according to the results of the univariate analysis (age, hemorrhage volume, intraventricular extension, glycemia, serum albumin, and Glasgow Coma Scale score at admission) using the Cox proportional hazards model. They also analyzed the survival curves according to the cholesterol and triglyceride quartiles.

RESULTS

Low serum cholesterol (p = 0.002; hazard ratio [HR] 0.988 [95% CI 0.979 to 0.997] mg/dL) and low serum triglyceride (p = 0.011; HR 0.986 [95% CI 0.976 to 0.997] mg/dL) concentrations were independently associated with increased in-hospital mortality after ICH. Analyzed by quartiles, the HR of in-hospital mortality was 3.136 (95% CI 0.833 to 11.087) for patients in the lowest cholesterol quartile (< 166 mg/dL) and 3.484 (95% CI 1.088 to 11.155) for patients in the lowest triglyceride quartile (< 74 mg/dL).

CONCLUSIONS

Low serum cholesterol and triglyceride levels obtained during the first hours after intracerebral hemorrhage (ICH) are strong independent predictors of in-hospital mortality in patients with spontaneous supratentorial ICH.

Association of lacunar infarcts with small artery and large artery disease: a comparative study

OBJECTIVES

Patients with lacunar infarcts (LI) and ipsilateral large artery disease (LAD) greater than 50% must be classified according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria as strokes of undetermined etiology. The purpose of this study was to compare the vascular risk factors, clinical symptoms, and outcome characteristics of LI associated with LAD with those patients with LI who fulfilled the TOAST criteria of small artery disease (SAD).

METHODS

Among 1754 consecutive first ever stroke patients admitted to our department, we analyzed age, gender, vascular risk factors (hypertension, diabetes, ischemic heart disease, arterial peripheral disease, hypercholesterolemia, smoking, alcohol, or illicit drug use), clinical data (motor or sensitive deficit and presence of dysarthria), and outcome (hospitalization length, in-hospital medical complications rate, need of rehabilitation, treatment at discharge, in-hospital mortality, and modified Rankin Scale at discharge) of those patients classified as LI associated with LAD as compared with those with SAD.

RESULTS

After a strict application of the TOAST criteria, we found 144 patients with LI associated with SAD and 73 patients with LI associated with LAD. Univariate analysis showed statistical differences in gender (OR: 0.46; 95% CI: 0.23-0.89; P = 0.014), past history of ischemic heart disease (OR: 0.32; 95% CI: 0.13-0.78; P = 0.004), and smoking (OR: 0.56; 95% CI: 0.31-1.04; P = 0.048). After logistic regression analysis only ischemic heart disease (OR: 0.31; 95% CI: 0.11-0.78; P = 0.013), and gender (OR: 0.51; 95% CI: 0.28-0.98; P = 0.05) showed statistical differences. During the follow-up, six patients (all with LI associated with LAD) experienced stroke recurrences (OR: 0.32; 95% CI: 0.26-0.39; P < 0.001).

CONCLUSIONS

1) There are no differences in clinical presentation and in-hospital outcome between patients with LI associated with SAD and patients with LI associated with LAD. 2) Risk factors are very similar in both groups, and the only differences observed (gender and ischemic heart disease) are related to the atherosclerotic factor. 3) Stroke recurrence seems to be more frequent in LI associated with LAD than in LI associated with SAD, but large follow-up studies are needed to be able to decide whether clinical recurrence of stroke allows to differentiate both clinical entities.

[Crazy laughter: first manifestation of a pontine tumour]

Crazy laughter (<<fou rire>>) was first described in 1903 as a prodromic symptom of an ischemic stroke and was later associated with brain lesions having a different location and etiology. We describe the case of a patient with a poorly differenciated pulmonary carcinoma who presented a centropontine image consistent with metastasis, whose initial manifestation was involuntary, persistent and unmotivated laughter that preceded other clinical manifestations. We revised, on the one hand, previous cases described in the literature of pathological laughter in relationship to structural lesions, of vascular or neoplastic etiology, and, on the other, the nervous centers and pathways that control the laughter mechanism.

[Crossed aphasia: description of a case]

We describe a new case of crossed aphasia in a right-handed patient with a right hemispheric lesion. A right-handed man, 76 year-old, developed a sudden left hemiparesis with sensitive impairment and mutism. He has neither family history of left handeness or ambidexterity or vascular risk factors. CT cerebral scan showed a large infarct of the middle cerebral artery on the right side, with haemorrhagic suffusion. Cerebral MRI and EEG-cartography confirmed the indemnity of the left hemisphere. Aphasia studies confirmed a mutism with spared verbal comprehension, but alexia was present. A year later, left hemiparesis was recovered but aphasia remained. Crossed aphasia is rarely seen. It is caused by a right hemispheric lesion in right-handed subjects. Fluency is most commonly impaired. At onset, mutism is the common symptom, which evolves to expressive aphasia. Several hypothesis have been raised about the possible mechanisms involved. The few number of PET or SPECT studies performed in these patients have disclosed extensive areas of hypometabolism in the right hemisphere, that exceed the size of the image observed with CT scan or MRI.