Your SlideShare is downloading. ×
0
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
• Stroke Mimics - Val Jones, St Helier Hospital
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

• Stroke Mimics - Val Jones, St Helier Hospital

1,298

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
1,298
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
42
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • Express study
    Compared usual practice of delayed assessment with revised protocol of prompt assessment ( no appointments, daily clinic) and start therapy in 24 hours (600 patients each group)
    Waiting time fell from 3 days to <1 day
    Delay of prescription to treatment fell from 20 days to 1 day
    SOS-TIA study
    Admission of TIAs Jan 2003-Dec 2005
    Assessment & imaging within 4 hours
    574 patients seen within 24 hours (53%)
    701 confirmed TIA/minor stroke (65%), 144 possible (13%)
    Commenced secondary prevention, 74% discharged same day
    90 day stroke rate 1.24% v 5.96% predicted (80% reduction)
  • Replicated in other series, common experience from practice
  • Focal deficit-hemiparesis, dysphasia, transient monocular blindness
    Unhelpful symptoms not TIA-weakness, lightheaded, blackout
  • Not going to talk about syncope as history and collateral should clarify
  • Aura starts gradually commonly hemianopic symptoms-fortification spectra, scotoma, shimmering lights, crescent, expanding. Symptoms mostly positive
    Sensory symptoms which spread-commonly up arm to face
    Dysphasia
    Often progression from one to the next
  • Usually in people with typical migraine when younger
    Harder to diagnose, particularly as will have increase stroke risk factors
  • Harder to diagnose initially
  • Repeat the same question over and over again No loss of personal identity No loss of consciousness Able to perform familiar activities e.g. driving
    Retrograde amnesia afterAfter patient has retrograde amnesia for the event
    Collateral history is paramount
    No increased risk of future vascular events
    Aetiology- no consensus
    pathology in ‘memory centres’- temporal lobes, hippocampus
    jugular-valve incompetence
    hypoxic-ischaemic origin
    personality types/phobic experiences
  • 75% chance being mimic compared to 21%
  • Transcript

    • 1. Stroke Mimics Dr Val Jones Consultant Stroke Physician Epsom & St Helier NHS Trust
    • 2. Outline • Importance & difficulty of TIA diagnosis • Diagnosing TIAs • Frequency and diagnosis commonest TIA mimics • Stroke mimics
    • 3.  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
    • 4. TIA-an opportunity to prevent stroke
    • 5.  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
    • 6. ABCD2 (Rothwell et al) Age >60yrs = 0 points ≥ 60yrs = 1 point BP at presentation SBP<140 & DBP<90 = 0 points SBP>140 or DBP≥90 = 1 point Clinical features Unilateral weakness = 2 points Speech 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
    • 7. 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
    • 8. 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%
    • 9. How good are we at diagnosing TIA?
    • 10. 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
    • 11.  Hypoglycaemia  Hyperventilation • Demyelination, • Entrapment neuropathy • Structural brain lesion  Intracerebral haemorrhage
    • 12. How do we recognise TIA?
    • 13.  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
    • 14. 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
    • 15. Normal CT Abnormal DWI image 82 year old man with transient dysphasia and incoordination R hand
    • 16. %  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)
    • 17.  Migraine  Epilepsy  Blackouts/syncope  Transient Global Amnesia  Metabolic Causes  Tumour  Psychogenic Common TIA mimics
    • 18. Migraine • Commonest mimic • Many forms • 3 main types recognised as stroke mimic • Migraine with aura • Aura without headache • Hemiplegic migraine
    • 19. 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
    • 20.  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
    • 21. Hemiplegic Migraine  May be familial  Typical headache  Stereotypical events
    • 22.  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
    • 23.  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
    • 24.  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
    • 25.  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
    • 26.  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
    • 27.  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
    • 28. Stroke Clinical 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
    • 29. Stroke diagnosis • History • Sudden onset • Rapid maximum • Fits known patterns of disease • Vascular risk factors • Careful examination • Imaging
    • 30. 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
    • 31. MS Tumour Functional Old stroke with intercurrent illness Epilepsy with Todd's paresis Encephalitis SAH Subdural
    • 32. Demyelination • Younger age group • Multiple episodes in time • and space • Diagnostic MRI
    • 33. Tumour • All age groups • Progressive history • Possible history of primary • Primary & secondary • Imaging diagnostic
    • 34. Functional • Younger • Atypical presentation • Signs that don’t fit • Hoover’s sign • Other worrying conditions • Typical gait • Normal imaging
    • 35. Epilepsy with stroke • Difficult to tease out whether new stroke + seizure or whether old stroke + seizure • DWI MRI helpful
    • 36. 65 Year old man with collapse and 2 Seizures. No previous history of stroke
    • 37. Importance of diagnosing stroke mimics  Access appropriate secondary prevention  Correct treatment for mimic  Avoidance of unnecessary drugs
    • 38. Summary • Importance of rapidly diagnosing and treating TIA • Diagnosis of TIA and stroke mimics

    ×