Stroke Mimics
Dr Val Jones
Consultant Stroke Physician
Epsom & St Helier NHS Trust
Outline
• Importance & difficulty of TIA diagnosis
• Diagnosing TIAs
• Frequency and diagnosis commonest TIA
mimics
• Stro...
 Often difficult
 Based on description
 Risk factor of stroke & IHD
 MRI may be helpful
Definition –
clinical syndrome...
TIA-an opportunity to prevent
stroke
 Risk of stroke in first week after TIA is 10%
 30% in highest risk group
 Half of events occur in first 48-72hrs
 Now...
ABCD2 (Rothwell et al)
Age >60yrs = 0 points
≥ 60yrs = 1 point
BP at presentation SBP<140 & DBP<90 = 0 points
SBP>140 or D...
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 sco...
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 t...
How good are we at
diagnosing TIA?
Final diagnosis in OCSP
 TIA 209 (38%)
 Other diagnoses 303 (62%)
 Migraine 52
 Syncope 48
 Possible TIA 46
 ‘Funny ...
 Hypoglycaemia
 Hyperventilation
• Demyelination,
• Entrapment neuropathy
• Structural brain lesion
 Intracerebral haem...
How do we recognise TIA?
 Time course of Symptoms
 Abrupt onset
 Maximal at onset
 Average 15 minutes
 Nature of Symptoms
 Focal deficit
 Qu...
MRI with DWI in TIA
• Recommended in NICE guidelines
• Positive in up to 50% patients
• More likely to be positive if unil...
Normal CT Abnormal DWI image
82 year old man with transient dysphasia and incoordination R hand
%
 Unilateral weakness 50
 Unilateral sensory symptoms 35
 Slurred speech 23
 Transient monocular blindness 18
 Diffi...
 Migraine
 Epilepsy
 Blackouts/syncope
 Transient Global Amnesia
 Metabolic Causes
 Tumour
 Psychogenic
Common TIA ...
Migraine
• Commonest mimic
• Many forms
• 3 main types recognised as stroke mimic
• Migraine with aura
• Aura without head...
Migraine with aura
1. At least 2 attacks
2. Headache with at least 3 of:
• Fully reversible focal aura symptom
• Aura deve...
 Commoner as older
 Can arise with no previous history of
migraine
 No excess risk of stroke
Fisher CM, Stroke, 1986
Au...
Hemiplegic Migraine
 May be familial
 Typical headache
 Stereotypical events
 Focal seizures can cause transient
neurological symptoms
 Symptoms start abruptly
 Symptoms spread over a minute or so...
 Can occur following partial or generalised
seizure
 Diagnosis clear with collateral history
 Stereotypical attacks
 A...
 Mean age 60
 11/100,000 each year
 Lasts a few hours typically < 24 hours
 Sudden disorder of memory-inability to
for...
 Attacks witnessed by observer
 Acute onset of anterograde amnesia
 No change of consciousness or loss of self-
awarene...
 Commonly hypo/hyperglycaemia or
hyponatraemia
 Hypoglycaemia can cause transient neuro
symptoms without classical sympa...
 Structural lesion in 0.5%
 Tumours, AVM
 Clinical features
 Focal jerking or shaking
 Pure sensory phenomena
 Loss ...
Stroke
Clinical syndrome characterised by rapidly
developing clinical symptoms and/or signs of
focal (or global) loss of c...
Stroke diagnosis
• History
• Sudden onset
• Rapid maximum
• Fits known patterns of disease
• Vascular risk factors
• Caref...
Incidence mimics
• Various studies 9-19% inpatients
• Mayo clinic study:
• July 2005-March 2006
• 196 patients
• 22% mimic...
MS
Tumour
Functional
Old stroke with intercurrent illness
Epilepsy with Todd's paresis
Encephalitis
SAH
Subdural
Demyelination
• Younger age group
• Multiple episodes in time
• and space
• Diagnostic MRI
Tumour
• All age groups
• Progressive history
• Possible history of primary
• Primary & secondary
• Imaging diagnostic
Functional
• Younger
• Atypical presentation
• Signs that don’t fit
• Hoover’s sign
• Other worrying conditions
• Typical ...
Epilepsy with stroke
• Difficult to tease out whether new stroke
+ seizure or whether old stroke + seizure
• DWI MRI helpf...
65 Year old man with collapse and 2
Seizures. No previous history of stroke
Importance of diagnosing
stroke mimics
 Access appropriate secondary
prevention
 Correct treatment for mimic
 Avoidance...
Summary
• Importance of rapidly diagnosing and
treating TIA
• Diagnosis of TIA and stroke mimics
• Stroke Mimics - Val Jones, St Helier Hospital
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• Stroke Mimics - Val Jones, St Helier Hospital

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

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