STROKE OR TIA - REAL OR IMITATION
Faculty: Frank L. Silver MD, FRCPC Professor of Medicine (Neurology), University of Toronto Medical Director, Toronto West Stroke Network Medical Director, Ontario Telestroke Program Adjunct Scientist, Institute for Clinical Evaluative Sciences Relationships with commercial interests : ► Consulting Fees : Boehringer Ingelheim Canada, National Coordinator for RESPECT ESUS RCT ► Speakers’ Bureau: Boehringer Ingelheim, Pfizer, Bristol-Myers Squibb Potential for conflict(s) of interest: ► Boehringer Ingelheim, Pfizer, Bristol-Myers Squibb develop and benefit from the sale of products that might be discussed in this program.
Mitigating Potential Bias ► All the recommendations involving clinical medicine are based on evidence that is accepted within the profession. ► All scientific research referred to, reported, or used is in the support or justification of patient care. ► Recommendations conform to the generally accepted standards. ► The presentation will mitigate potential bias by ensuring that data and recommendations are presented in a fair and balanced way. ► Potential bias will be mitigated by presenting a full range of products that can be used in this therapeutic area. ► Information of the history, development, funding, and the sponsoring organizations of the disclosure presented will be discussed.
Making a diagnosis after the symptoms have resolved is difficult
Learning Objectives 1. To discuss neurological and non-neurological conditions that mimic stroke and TIA 2. To discuss the clinical features that differentiate between stroke and these mimics 3. To provide an approach, including relevant investigations, to assist in determining the etiology of an ischemic stroke
Why is stroke important? • Stroke is common – one of the leading reasons for admission to an adult hospital • Stroke can be devastating – the leading cause of adult disability and a huge cost to society • Stroke is treatable – revascularization with thrombolytics and mechanical thrombectomy • Stroke is preventable – more than half of all stroke could be prevented by applying what we already know
Acute strokes can be very bad!
The Definition of Stroke is a clinical syndrome characterized by the sudden onset of a focal neurological deficit presumed to be on a vascular basis
TIA vs. Ischemic Stroke ? 61 year old man with a history of sudden right face and arm weakness and speech difficulties lasting 20 minutes CT Scan 4 hours MR Scan 4 hours (DWI)
Definition of TIA (revised recently) a clinical syndrome characterized by the sudden onset of a focal neurological symptoms that resolves within 24 hours AND there is no evidence of infarction on brain imaging
Making the Right Diagnosis The Four Questions • Is it a stroke? • Where is the lesion? – What is the vascular supply ? • What is the lesion? – Hemorrhage vs Infarct/Ischemia • What is the etiology?
Stroke Mimics • Any focal lesion Imaging Positive – tumour, abscess – demyelination • Seizures (post-ictal Todd’s) • Old strokes • Hysterical conversion • Migraine
Frequency and Type of Stroke / TIA Mimics Top Ten Mimics Migraine Syncope BPPV Seizures 338 / 1532 (22%) of the Functional / Anxiety patients had mimics TGA Bell’s Palsy Peripheral Nerve Disease Postural Hypotension Tumour Nadarajan V, et al. Pract Neurol 2014;14:23–31
Factors to consider • The presence of vascular risk factors / age of patient • Focal vs non-focal symptoms • Positive vs. negative symptoms • Type of symptoms – motor, speech, visual vs. sensory • Duration of symptoms • Accompanying symptoms – Pain – headache, neck pain, chest pain – Cardiac symptoms – palpitations, SOB, – Seizure – Post-ictal confusion, incontinence, tongue biting – Ear – hearing loss, tinnitus
Stroke / TIA • Presence of vascular risk factors • Onset is sudden, maximal at onset without progression • Focal negative symptoms – motor weakness, speech (dysarthria and/or aphasia), visual (field loss, diplopia) • Not isolated – vertigo / diplopia / sensory loss / memory • Duration – at least 10 minutes (not 10 seconds) • One or two episodes – worry; many episodes usually benign • Associated symptoms – headache, pulsatile tinnitus, palpitations
Migraine • Common • Family history • Onset usually at early age, however, late-onset acephalgic migraine is common • Aura - evolving positive focal symptoms – usually visual, progressing over minutes, can progress stepwise from visual, to sensory, to speech • Duration – typically 10 – 30 minutes
Seizure • brief, lasting 1 - 2 minutes, recurrences stereotyped • often focal onset – with progression over seconds (Jacksonian March) • post-ictal confusion / drowsiness +/- Todd’s paralysis • tongue biting, incontinence • ask about hallucinations of taste, smell, déjà vu • imaging shows a focal lesion • EEG may be helpful
TIA Migraine aura Focal Seizures Predisposition • CAD, PVD • Migraines • Brain lesion • Atherosclerotic risk factors Cardiovascular • Frequent • Absent • Absent manifestations Neurological • Negative (deficit) • Positive • Positive manifestations • Visual > sensory >speech • Headaches • ≤ 2 minutes with Symptom onset • Sudden • >10 minutes with progression progression • ≤ 5 minutes Duration • 5-10 minutes • 20 minutes (or more) Sylvain Lanthier
Syncope / Pre-syncope • cardiac history – angina / prior MI, palpitations • often volume depleted or on new medication • often a prodrome – nausea, NFW, pallor, sweating, vision blurred / diminishing • often postural or when standing • lightheaded, not vertigo • no focal neurological signs • no post-ictal confusion • rarely incontinence
Conversion • history of previous functional illness • secondary gain • symptoms / signs do not make sense physiologically – do not follow myotomes, dermatomes – absence of abnormal reflexes – inconsistent – e.g. can weight bear / but cannot lift against gravity • symptoms fluctuate and improve with encouragement – BEWARE of myasthenia gravis • normal imaging
Peripheral vestibulopathy • true vertigo, often positional • no other focal neurological symptoms – no diplopia, dysarthria, dysphagia, focal weakness / sensory loss, – no ataxia (except when severely vertiginous) you must examine the patient’s gait • tinnitus, hearing loss • often recurrent over time
How often is acute dizziness related to an acute TIA / stroke? Population based study in Nueces County, Texas (2011–2012) of patients presenting to an emergency department with acute dizziness 1,273 patients age ≥45 followed median 347 days • Stroke was diagnosed in 25 (2.2%) of the patients. • Of the remaining 1,245 non-stroke dizzy patients - 15 (1.2%) had a stroke in follow-up Note: Dizziness was defined as a presenting symptom of “dizziness,” “vertigo,” or “imbalance.” Kerber KA et al. Ann Neurol 2014 75:899-907.
Transient Global Amnesia • sudden loss of recent and ongoing memory • patients still know who they are and recognise their family / friends • lasts hours • no other neurologic deficits • associated with migraine ✓ ✘
Metabolic / Toxic Disorders • Hypoglycemia – focal findings can be present – corrects with glucose but may take time • Acute metabolic / infectious disturbance with focal findings related to a past stroke • Hyperglycemia • Hypocalcemia • Hyponatremia • Hepatic encephalopathy • Ethanol and other psychotropic drugs
Just to confuse us, these are really on the basis of cerebral ischemia / infartion • Capsular Warning Syndrome • Limb-shaking TIAs • Penduncular Hallucinations • Brain stem posturing / involuntary movement • Anton’s Syndrome – cortical blindness • Hemiballismus – infarct of the subthalamic nucleus
The Value of Imaging • Brain Imaging (CT / MR) – evidence of old infarcts / hemorrhages – evidence of acute infarction / hemorrhage • Vascular Imaging (CTA, MRA, DSA, Duplex doppler) – significant arterial stenosis / occlusion of a relevant artery – other vascular lesions – AVMs, aneurysms, SVT • Perfusion imaging (CTP, MRP) – perfusion abnormality
Left MCA Stroke: Frontal Lesions
Diffusion Weighted MRI - cardioembolic
CT Head: September 21, 2016 12:56 hours
CTA September 21, 2016 12:56 hours
RAPID CTP September 21, 2016 12:56 hours
Risk of Early Recurrent Stroke Increased Risk for Early Stroke: motor weakness speech disturbance symptoms > 10 minutes diabetes age > 60 90 day risk of stroke following a TIA is ~ 10% half occur with in the first 48 hours
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