Stroke mimicker

and

Unusual cause of stroke

Surat Tanprawate, MD, MSc(London), FRCP(T) Division of Neurology, Chiangmai University
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Stroke Cerebrovascular accident Cerebrovascular disease

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1.When the time is brain... rt-PA is a good choice

Since 1995
rt-PA era
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Sudden onset of neurological decit

3 hrs->4.5 hrs->6 hrs->12 hrs

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But...

Stroke mimics, non-vascular conditions that simulate stroke

Stroke. 2009;40:1522-1525

250 rt-PA treated patients, 243 (97.2%) had strokes and

7 (2.8%) were mimics (and was received rt-PA

Dont forget that rt-PA increase risk of hemorrhage 6%
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Stroke mimicker
Stroke mimic is the term employed for The mimics include both processes
manifestations of nonvascular disease processes when a stroke-like clinical picture is produced occurring within the CNS and systemic events

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800 consecutive patients admitted to a stroke unit from the emergency department of a Canadian hospital They found the initial diagnosis of stroke incorrect in 13% of patients
Ay H et al. Neurology. 1999;52:1784-1792.

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Condition that mimic stroke

miscellaneous SAH TGA vertigo MS syncope/presyncope dementia psychogenic migraine confusional state SDH tumour PN palsy toxic/metabolic seizures 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 18.2% 3.6% 3.1%

% of all stroke mimics (n=670)

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Seizure and Todds paralysis

Robert Benley Todd (1809-1860) Irish-born London physiologist

Todds paresis (post-ictal paralysis) is focal weakness in a part of the body after a seizure Common in generalized tonic clonic seizure, or partial seizure occur in 13% of the seizure patient recovery within 36 hours

Exhausted seizure brain

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Variant of Todds paralysis

Postictal apraxia and prolonged postictal

hemineglect
Helmchen C, Steinhoff BJ, Dichgans M. Nervenarzt 1994 Oct;65(10):700-3.

Bilateral Todd's paralysis after focal

seizures
Bergen DC, Rayman L, Heydemann P. Epilepsia. 1992 Nov-Dec;33(6):1101-5

Mute postseizure patient: an unusual

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manifestation of Todd's phenomenon.

LaCapra S, King C. Ann Emerg Med. 1994 Apr;23 (4):877-80.

Post-stroke seizure
or Todds paralysis

Stroke can produce seizures

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intracranial hemorrhage embolus

Some clinical clues to differentiate both what come rst; weak or seizure type of neurological decit recovery imaging

Be aware:
imaging in post-ictal encephalopathy
In patient with status epilepticus; the imaging may change

An MRI brain of a Thai woman with status epilepticus, with no evidence of other cause of encephalopathy, showed temporal lobe lesion
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Migraine-the great mimicker

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Aura alone Uncommon aura: dysphasia, weakness,

vertigo, coma

Prolong aura: more than 60 minute

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Migraine Aura
99% 31%

Typical aura: -Visual -Sensory -Speech

6%

18%

n=163
Michael B. R. et al. Brain 1996: 119, 355-361
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Migraine aura vs TIA

Feature onset progressive rate different symptoms type of visual symptoms territory duration Migraine progressive slow in succession negative or positive cortical long (30-60 min) TIA sudden non simultaneous negative vascular short (10-15 min)

Jean Schoenen and Peter S Sndor. Lancet Neurol 2004; 3: 23745

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Can migraine induce infarct?

Migraine with aura (MA)
WMLs in migraine brain

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Double stroke risk: women, < 45 years, smoker, oral contraceptive pill used associated with subclinical WMLs migrainous infarct
T2-weight MRI show upper pons lesion in migrainous infarct
Kruit MC, et al. Cephalalgia 2010 30: 129
Lee H, Whitman GT et al. Arch Neurol.2003;60:113-116

Hemiplegic migraine
Description

Migraine with aura including motor weakness

Familial Hemiplegic Migraine (FHM)

at least one rst- or second- degree

Sporadic Hemiplegic Migraine (SHM)

relative has migraine aura including motor weakness

no rst- or second-degree relative has

aura including motor weakness
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Tumor and stroke-like

H98IPPOKRATIA 2008, 12, 2: 98-102

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Tumor and stroke like

6% of brain tumor patients had symptoms that were of less than one days duration (at the Emergency department) acute onset of tumor could be...

hemorrhage into tumor obstructive hydrocephalus secondary effect from of mass or edema on cerebral vasculature

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Toxic/Metabolic-???
Hypoglycemia and focal paresis -a case description

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Functional hemiparesis
Conversion disorder is the most
commonly assigned psychiatric disorder presentations of conversion disorder noted that symptoms of paresis, paralysis, or movement disorders were common and were a presentation in almost 30% of patients.

One study of emergency department

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Hoovers sign: testing functional weakness

J Stone, A Carson, M Sharpe J Neurol Neurosurg Psychiatry 2005;76:i2-i12
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functional sensory disturbance

functional gait disorder

J Stone, A Carson, M Sharpe J Neurol Neurosurg Psychiatry 2005;76:i2-i12

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2. The clinical suggesting stroke is abrupt onset of neurological decit

Point...
Not all stroke patient come with sudden neurological decit Strokes with atypical presentations that take on the appearance of other disease process

stroke cameleons

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Stroke chameleons

what is common...hemiparesis, sensory loss, ataxia, language disorder, visual loss, vertigo what is uncommon...

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uncommon manifestation: movement disorder, behavior abnormality, pain, isolated memory loss.. etc uncommon time-course...slow progressive, uctuation

3. the major cause of stroke is atherosclerosis

Cardiac embolism

Atherosclerosis
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Stroke can be...

Ischemic 75%

TOAST classication

Large-artery atherosclerosis(emboli/ thrombosis) Cardioembolism(high-risk/mediumrisk) Small-vessel occlusion(lacune) Stroke of other determine etiology Stroke of undetermined etiology

Hemorrhagic (25%); subarachnoid, intracerebral

HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41

TOAST, Trial of Org 10172 in Acute Stroke Treatment.

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Uncommon cause of stroke... the non-atherosclerotic stroke

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Dissection Inammatory vasculopathy Trauma Moyamoya Radiation vasculopathy Inherit disorder

Infection and stroke Drug abuse and stroke Stroke and systemic vasculitis migraine and stroke Fibromuscular dysplasia Hypercoagulable state

Clinical clues
Stroke in the young No atherosclerotic risk Underlying of particular disease; SLE,
AIDS, carcinoma, migraine

Atypical presentation Fail to conventional treatment

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Causes of Infarction in 100 Young Adults

RG Hart and VT Miller Stroke 1983, 14:110-114

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How to make a stroke diagnosis?

RG Hart and VT Miller Stroke 1983, 14:110-114

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