• Stroke Mimics - Val Jones, St Helier Hospital
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Transcript of • Stroke Mimics - Val Jones, St Helier Hospital
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Stroke Mimics
Dr Val JonesConsultant Stroke PhysicianEpsom & St Helier NHS Trust
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Outline
• Importance & difficulty of TIA diagnosis
• Diagnosing TIAs
• Frequency and diagnosis commonest TIA mimics
• Stroke mimics
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Often difficult Based on description Risk factor of stroke & IHD MRI may be helpful
Definition – clinical syndrome characterised by sudden onset focal neurological disturbance lasting <24 hours and which is thought to be due to vascular cause (low blood flow, arterial thrombosis, embolism) or associated diseases of the arteries, heart or blood
Hankey and Warlow. Transient Ischaemic attacks of the Brain and Eye, 1994
Diagnosis of TIA
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TIA-an opportunity to prevent stroke
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Risk of stroke in first week after TIA is 10% 30% in highest risk group Half of events occur in first 48-72hrs
Now a method of risk stratifying TIAs: ABCD2 score
Importance of TIAs
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ABCD2 (Rothwell et al)
Age >60yrs = 0 points 60yrs = 1 point
BP at presentation SBP<140 & DBP<90 = 0 points SBP>140 or DBP90 = 1 point
Clinical features Unilateral weakness = 2 pointsSpeech disturbance = 1 point
Sensory loss/other symptom=0pt
Duration of symptoms 60 minutes = 2 points 10-59 mins = 1 point < 10 mins = 0 points
Diabetes absent=0 points present=1 point
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ABCD2 Score % risk of stroke at 7 days (95% CI)
<4 0
4 2.2 (0-6.4)
5 16.3 (6.0-26.7)
6-7 35.5 (18.6-52.3)
High Risk if score ≥4 or recurrent episode in same week
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80% risk reduction of stroke at 90 days from 10.3% to 2.1%.
80% risk reduction of stroke at 90 days from 5.96% predicted to 1.24%
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How good are we at diagnosing TIA?
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Final diagnosis in OCSP
TIA 209 (38%)
Other diagnoses 303 (62%) Migraine 52 Syncope 48 Possible TIA 46 ‘Funny Turn’ 45 Isolated vertigo 33 Epilepsy 29 Transient Global Amnesia 17 Dennis MS et al, Stroke 1989
Accuracy of Diagnosis
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Hypoglycaemia Hyperventilation• Demyelination, • Entrapment neuropathy• Structural brain lesion Intracerebral haemorrhage
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How do we recognise TIA?
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Time course of Symptoms Abrupt onset Maximal at onset Average 15 minutes
Nature of Symptoms Focal deficit
Quality of Symptoms Negative Sandercock PAG, Quarterly Journal Of
Medicine, 1991
Clinical Diagnosis of TIA
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MRI with DWI in TIA• Recommended in NICE guidelines• Positive in up to 50% patients• More likely to be positive if unilateral
weakness, longer duration, higher ABCD2 score or AF
• More likely to have early stroke with +ve DWI
• If positive independent risk factor for early stroke risk
Calvet et al Stroke 2009
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Normal CT Abnormal DWI image
82 year old man with transient dysphasia and incoordination R hand
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% Unilateral weakness 50 Unilateral sensory symptoms 35 Slurred speech 23 Transient monocular blindness 18 Difficulty speaking 18 Unsteadiness 12 Vertigo 5 Homonymous hemianopia 5 Double vision 5 Bilateral limb weakness 4 Difficulty swallowing 1 Crossed motor &sensory signs 1
(OCSP data, Dennis,1988)
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Migraine Epilepsy Blackouts/syncope Transient Global Amnesia Metabolic Causes Tumour Psychogenic
Common TIA mimics
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Migraine• Commonest mimic• Many forms• 3 main types recognised as stroke
mimic• Migraine with aura• Aura without headache• Hemiplegic migraine
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Migraine with aura
1. At least 2 attacks 2. Headache with at least 3 of:
• Fully reversible focal aura symptom• Aura develops gradually > 4 mins• No aura symptom lasts>60 mins• Headache follows aura within 60 minutes
3. Other conditions excluded
ICHD-2 criteria
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Commoner as older Can arise with no previous history of
migraine No excess risk of stroke
Fisher CM, Stroke, 1986
Aura without headache
Dennis and Warlow, J of Neurology, Neurosurgery and Psychiatry, 1992
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Hemiplegic Migraine
May be familial Typical headache Stereotypical events
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Focal seizures can cause transient neurological symptoms
Symptoms start abruptly Symptoms spread over a minute or so-
shorter than with migraine Symptoms are mainly POSITIVE
jerking tingling
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Can occur following partial or generalised seizure
Diagnosis clear with collateral history Stereotypical attacks Antecedent symptoms Difficulty with negative symptoms
Epilepsy with Todd’s paresis
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Mean age 60 11/100,000 each year Lasts a few hours typically < 24 hours Sudden disorder of memory-inability to
form new memories• Mistaken for acute confusional states• No increased risk of stroke
Sander and Sander, Lancet Neurology, 2005
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Attacks witnessed by observer Acute onset of anterograde amnesia No change of consciousness or loss of self-
awareness No recent head trauma or seizures Duration of symptoms 1- 24 hours No neurological symptoms bar dizziness, vertigo
or headache
Hodges and Warlow, Journal of Neurology, Neurosurgery and Psychiatry, 1990
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Commonly hypo/hyperglycaemia or hyponatraemia
Hypoglycaemia can cause transient neuro symptoms without classical sympathetic response
Commonly in people on hypoglycaemic agents Pre-meals, post-exercise, nocturnal Always check BM
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Structural lesion in 0.5% Tumours, AVM Clinical features
Focal jerking or shaking Pure sensory phenomena Loss of consciousness Isolated aphasia or speech arrest
UK TIA Study Group, J of Neurologgy, Neurosurgery and Psychiatry, 1993
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StrokeClinical syndrome characterised by rapidly developing clinical symptoms and/or signs of focal (or global) loss of cerebral function with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin
Hatano, 1976
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Stroke diagnosis• History
• Sudden onset• Rapid maximum• Fits known patterns of disease• Vascular risk factors
• Careful examination• Imaging
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Incidence mimics• Various studies 9-19% inpatients• Mayo clinic study:
• July 2005-March 2006• 196 patients• 22% mimics
Strongest predictor mimic: absence localising signs, low DBP, Hx stroke/TIA
Bentley, Bobrow et al
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MSTumourFunctionalOld stroke with intercurrent illnessEpilepsy with Todd's paresisEncephalitisSAHSubdural
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Demyelination• Younger age group• Multiple episodes in time• and space• Diagnostic MRI
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Tumour• All age groups• Progressive history• Possible history of primary• Primary & secondary• Imaging diagnostic
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Functional• Younger• Atypical presentation• Signs that don’t fit• Hoover’s sign• Other worrying conditions• Typical gait• Normal imaging
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Epilepsy with stroke
• Difficult to tease out whether new stroke + seizure or whether old stroke + seizure
• DWI MRI helpful
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65 Year old man with collapse and 2 Seizures. No previous history of stroke
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Importance of diagnosing stroke mimics
Access appropriate secondary prevention
Correct treatment for mimic Avoidance of unnecessary drugs
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Summary• Importance of rapidly diagnosing and
treating TIA• Diagnosis of TIA and stroke mimics