In the era of
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350 patients referred to stroke team
54 did not have stroke
1% Previous stroke and new intercurrent illness
Migraine the doctor in the Emergency Room?
Spinal cord stroke
Spinal cord compressionOther mimics
Assessed 350 patients
(92% admitted through ARU)
18.6% were stroke mimics
Syncope the doctor in the Emergency Room?
Spinal Cord Lesion
Transient global amnesiaStroke Mimics 2000
Need to reflect on the definition of stroke and TIA
Stroke stroke mimic?
A clinical syndrome characterized by rapidly developing clinical symptoms and/or signs of focal, and at times global (applied to patients in deep coma and those with subarachnoid haemorrhage), loss of cerebral function, with symptoms lasting more than 24 hours, or leading to death, with no apparent cause other than that of vascular origin.
Transient ischaemic attack (TIA) stroke mimic?
A clinical syndrome characterized by an acute loss of focal cerebral or monocular function with symptoms lasting less than 24 hours and which is thought to be due to inadequate cerebral or ocular blood supply as a result of low blood flow, arterial thrombosis or embolism associated with diseases of the arteries, heart or blood.
Hankey & Warlow 1994
TIA: Ischaemic stroke continuum stroke mimic?
Anything which causes a TIA, will, if prolonged cause a stroke.
Quantitatively, not qualitatively, different
Koudstaal et al 1992 JNNP;55:95
Strokes are common in old people with vascular disease
How old are they?
If young (<60 years old) have they premature vascular disease or have they an unusual cause of stroke (e.g. a right to left shunt from patent foramen ovale)
Have they got vascular disease?
Previous heart attacks, diabetes, hypertension, previous stroke or TIA, high cholesterol?
Were they previously well?
Acute brain attack relevant infarct on CT
Other metabolic causes
Exclude tumour /structural lesion
PICH, SAH, Subdural
Stroke relevant infarct on CTIS an Emergency!
AMBULANCE relevant infarct on CT
The Brain Attack Team: the need for investment
Acute stroke units
Pharmacy & Laboratory
Confirmed ischaemic relevant infarct on CT
Are the symptoms/signs resolving rapidly?
Are the symptoms/signs disabling?
Treat like TIA
Consider more intensive treatment
Definitions of TIA and Stroke a bit out of date
The new paradigm of Brain Attack may be useful
There are many non-cerebrovascular causes of brain attack
Mrs X 78 years old
Perfectly well until day of presentation
Wife noticed that he was “not himself”
Collapsed and brought into A&E dept
Was noted to be aphasic (language problem) and right sided weakness
Then had an epileptic fit
CT scan relevant infarct on CT
Showed a problem in the appropriate hemisphere
Interpreted as being early ischaemia
Admitted to stroke unit
Developed status epilepticus
Is this a stroke?
CT scan reviewed relevant infarct on CT
Odd swollen appearance
Possibly herpes simplex encephalitis
Despite anticonvulsants, and anti-viral therapy, patient died.
Post mortem showed...
Post mortem examination relevant infarct on CT
Brain tumour cells found throughout entire brain
Did eventual tumour mass cause electrical instability?
A common mimic of “stroke” in emergency medicine is brain tumour (a cause of about 3-5% of all initial “stroke” diagnoses).
Clues: CT scan appearance very atypical for stroke
Status epilepticus rare after acute stroke
A 72 year old lady with known bladder cancer (transitional cell carcinoma) presents with mild left sided weakness.
Right frontal lesion is a primary intracerebral haemorrhage stroke
The left frontal lesion is an incidental meningioma
Stroke affects older people and co-morbidity is common
About 10% of all stroke is due to primary intracerebral haemorrhage
Pathology of stroke can now be reliably established by CT scanning done within hours/days of the event
Cerebral infarction 80%
Primary intracerebral haemorrhage 10%
Subarachnoid haemorrhage 5%
Sudlow & Warlow 1997
Systematic review of world-wide incidence studies
64 year old man was driving his car and he suddenly lost power in his right arm and leg
He had no headache
No loss of consciousness
Called for help and son brought him to casualty
No significant medical history
Blood pressure 200/120 mmHg
Complete weakness affecting his right face, arm and leg
Presents with a sudden onset of dizziness and headache
On examination she had nystagmus
Six hours after admission started to complain of worsening headache
24 hours later was unconscious
Is this a stroke?
Mrs X 69 years old
Developed Right hemiparesis and aphasia during breakfast (9am)
Husband called GP and sent immediately to A & E department
Severe (0/5) right face, arm and leg weakness scanning done within hours/days of the event
Dyspraxia (disorganised movement of body)
Aphasic (no understanding or expression of language)
Dense MCA sign indicating thrombus in the left MCA