stroke or tia - real or imitation
TRANSCRIPT
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STROKE OR TIA - REAL OR IMITATION
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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.
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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.
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Making a diagnosis after the symptoms have resolved is difficult
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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
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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
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Acute strokes can be very bad!
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is a clinical syndrome characterized
by the sudden onset of a focal neurological deficit presumed to be
on a vascular basis
The Definition of Stroke
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TIA vs. Ischemic Stroke ?
CT Scan 4 hours MR Scan 4 hours (DWI)
61 year old man with a history of sudden right face and arm weakness and speech difficulties lasting 20 minutes
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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
Definition of TIA (revised recently)
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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?
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Stroke Mimics • Any focal lesion
– tumour, abscess – demyelination
• Seizures (post-ictal Todd’s)
• Old strokes
• Hysterical conversion
• Migraine
Im
agin
g P
ositi
ve
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338 / 1532 (22%) of the patients had mimics
Nadarajan V, et al. Pract Neurol 2014;14:23–31
Frequency and Type of Stroke / TIA Mimics
Top Ten Mimics Migraine Syncope
BPPV Seizures
Functional / Anxiety TGA
Bell’s Palsy Peripheral Nerve Disease
Postural Hypotension Tumour
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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
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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
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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
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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
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TIA Migraine aura Focal Seizures Predisposition • CAD, PVD
• Atherosclerotic risk factors
• Migraines • Brain lesion
Cardiovascular manifestations
• Frequent • Absent • Absent
Neurological manifestations
• Negative (deficit) • Positive • Visual > sensory
>speech • Headaches
• Positive
Symptom onset • Sudden • >10 minutes with progression
• ≤ 2 minutes with progression
Duration • 5-10 minutes (or more)
• 20 minutes • ≤ 5 minutes
Sylvain Lanthier
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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
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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
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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)
• tinnitus, hearing loss
• often recurrent over time
you must examine the patient’s gait
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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.
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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
✓ ✘
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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
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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
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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
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Left MCA Stroke: Frontal Lesions
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Diffusion Weighted MRI - cardioembolic
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CT Head: September 21, 2016 12:56 hours
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CTA September 21, 2016 12:56 hours
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RAPID CTP September 21, 2016 12:56 hours
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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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ABCD2 • A – age 60 years or older (1 point)
• B – blood pressure elevation on first assessment after TIA (1 point; systolic ≥140 mm Hg or diastolic
• C – clinical features of TIA (unilateral weakness, 2 points; or speech impairment without weakness, 1 point);
• D – duration of TIA (≥60 minutes, 2 points; or 10–59 minutes, 1 point)
• D – diabetes (1 point)
In 4799 patients 2-day risk of stroke was: » 1·0% with a score of zero to three (low risk) » 4·1% with four or five (moderate risk) » 8·1% with six or seven (high risk)
Johston, Rothwell, et al. Lancet 2007; 369:283-92
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Small infarct
Diffusion Weighted MR
Coutts SB, Simon JE, Eliasziw M, et al Ann Neurol 2005;57:848–854
MR Findings
30-day Risk of Stroke
Overall
No DWI Lesion
DWI Lesion & Vessel Occlusion
11.7%
4.4
32.6
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Dai Q. et al Neurol 2015;84:1426-1432
ABCD3-I Score!
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Risk of Recurrent Stroke at One Year
TIAregistry. org Project • TIA / Minor Stroke with 7 days • seen in rapid TIA clinic
One Year Risk • Stroke, MI, Vascular Death 6.2% • Stroke 5.1% (3.7% at 90 days)
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Risk of Recurrent Stroke at One Year
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Ontario Stroke Registry • ED patients with TIA / Minor Stroke • 2008/9 and 2010/11
Kapral MK et al Neurology 2016;86:1-8.
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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?
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Ischemic Stroke: Mechanisms
BLOOD VESSELS
BLOOD
HEART
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Investigations • Image the brain
– to determine the location, size and pattern of the infarct(s)
• Image the arteries – to look for an embolic source – to explain a hemodynamic mechanism
» look for proximal occlusion/ stenosis » assess the collateral circulation
• If suspected – assess cerebral perfusion or CVR
• Look for a cardiac source – echo, Holter, cardiac MR
• Look for a prothrombotic state
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Ischemic Stroke by Etiology
Adapted from the Stroke Databank Lancet Neurol 2014; 13: 429-38
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ESUS
Lancet Neurol 2014; 13: 429-38
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Ischemic Stroke by Etiology
20%
25%
30%
20%
5% LAACardioemLacunarUnknownOther
Adapted from the Stroke Databank
Anticoagulant Rx
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Casaubon et al. Int J Stroke. 2015 Aug;10(6):924-40.
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http://www.strokebestpractices.ca
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