Acute cerebral infarction venous thrombolysis, must exclude such diseases!

*For medical professionals only

Stroke simulation is also known as pseudostroke or stroke-like stroke

Clinically encountered patients suspected of acute cerebral infarction, is it really diagnosed with cerebral infarction in the end? There is a disease that brings great interference to the diagnosis of clinicians, and I will take a look at it
below.

What is a stroke simulation disease

       

 

Stroke mimics (SM), also known as pseudostroke or stroke-like stroke, refers to a large group of diseases in the early stage of the disease, the patient's clinical symptoms and signs are similar to stroke (limb paralysis, facial paralysis, aphasia, consciousness impairment, etc.
), and after detailed history inquiry, examination, evaluation and follow-up, it is finally confirmed that the patient is not a group of stroke diseases
.

At present, there is no unified definition, in the daily emergency department and green channel work, stroke simulation disease because of its clinical symptoms and signs similar to stroke, easy to cause emergency physicians or neurology first physician misjudgment
.

Stroke simulation disease contains which diseases

       

Common SMs include seizures, migraines, tumors, venous infarction, reversible posterior encephalopathy syndrome (PRES), and subdural edema
.

In addition, other disorders rarely mimicking acute cerebral infarction include infections (encephalitis, abscesses, meningitis, sepsis), metabolic abnormalities (hypoglycemia, hepatic encephalopathy), demyelinating disease, and mitochondrial encephalopathy with lactic acidosis (MELAS
).

Emergency departments and neurologists must be aware of these SMs and minimize errors or delays in diagnosis
.

▌ SeizuresSeizures are the most common type of SM, and seizures
often present as stereotyped motor and paresthesias, especially in patients with Todd paralysis or paroxysmal aphasia/dysphagia
.

The probability of misdiagnosis of seizure aphasia and hemiparesis in epilepsy is as high as 40%.

Epilepsy-related cortical signaling abnormalities may be associated
with DWI abnormalities.
Therefore, epilepsy
needs to be excluded in the diagnosis of stroke.

▌ Migraine usually has a typical history of migraine
, and may have auras such as headache and photophobia
.
The first episode of hemiplegic migraines, usually around the age of 45, is often confused with transient ischemic attacks (TIAs) and is often treated
as a stroke.
Neuroimaging is mostly normal
.

Most clinicians agree that hesitation about diagnosis often delays treatment
.
Some patients develop migraine before the age of 30 years, followed by infarction of the blood supply area of the middle cerebral artery
.
In order to avoid the regret of lifelong disability for some young patients, it has been felt that timely thrombolytic therapy
is needed for such patients.

▌ Patients
with tumors may suddenly have "stroke-like" symptoms
.
Misdiagnosis
often occurs when the tumor is small, located in the cortex, and has different patterns of enhancement in arterial distribution.

The most common initial symptoms in misdiagnosed patients are changes in vision and aphasia, but there are also long-standing symptoms
of pure motor hemiparesis.
DWI may show different signaling features (depending on tumor cells), increased glioma perfusion, including elevated cerebral blood volume (CBV) (compared to low CBV expected in acute infarction).


The exact mechanism of stroke-like manifestations is unclear, but hemorrhage or neoplastic stroke, subacute intracranial pressure changes, decreased cerebral blood flow, tumor emboli and vascular compression or envelopment may all be causes
.

Common clinical brain tumors include gliomas such as gliomas and meningiomas, and central nervous system lymphomas and anaplastic astrocytomas have also been reported
.

▌ Venous infarction
cerebral venous thrombosis has different distribution characteristics compared with arterial infarction, and usually lacks arterial distribution
.
DWI abnormalities are variable in venous infarction
.

Venous infarction may show flame-like bleeding
.
CTA may confirm localized obstruction or diffuse atherosclerosis
.
Sensitivity is over 70% and specificity is 88% ^[3].

It is not widely used
due to limitations of CTA examination.

Cortical vein thrombosis may be accompanied by focal convex subarachnoid hemorrhage, which can be observed on gradient echo T2 or a susceptibility-weighted sequence, and CT may show a "δ" sign
.

▌ Reversible posterior encephalopathy syndrome
PRES is mainly manifested by headache, seizures, altered mental status, and visual changes or loss of symptoms
.
A clinical imaging diagnosis characterized by transient failure of autovascular regulation leading to multifocal angioedema
.

Patients with malignant hypertension, eclampsia, chemotherapy, or post-transplant medications appear to be particularly susceptible
.
Usually the PRES lesion is bilateral, subcortical, non-enhanced, mainly involving the parietal occipital area, and can recover
after a few weeks.

▌Subdural hematoma subacute to chronic subdural hematoma exhibits clinical symptoms of stroke, including stroke, ataxia, and hemiplegia

.
Easy to identify on CT and MRI
.

▌ Hypoglycemia in adults with hypoglycemia
often has more typical symptoms, mainly manifested as sympathetic nervous excitatory symptoms, such as hunger, palpitation, shaking hands, sweating, limb weakness and so on
.

Hypoglycemia that occurs in the elderly either has no symptoms (i.
e.
, asymptomatic hypoglycemia) or is manifested by neuropsychiatric symptoms such as speech and behavior abnormalities, convulsions, hemiplegia, impaired consciousness, drowsiness, coma, etc.
, and can easily be misdiagnosed as acute stroke or seizure.


▌ Syncope
episodes are likely to be misdiagnosed as vertebrobasilar system strokes
.
Although strokes in the vertebrobasilar artery system often present with altered consciousness, they are often accompanied by signs of unilateral cranial nerve damage such as diplopia, dysarthria, vertigo, and ataxia
.

▌ Systemic disease stale stroke patients under the influence of systemic
diseases (such as hyponatremia, lung or urinary tract infections, sepsis or severe fatigue, etc.
) may appear in the same blood supply area of acute or subacute symptoms and signs of deterioration, cranial CT shows as an old lesion in the same area, clinically new symptoms
.

When sepsis or other causes are treated, the patient's condition improves
.

Evaluation of stroke mimetic disease

       

TM scores and FABS scale scores are often used clinically to predict stroke mimetic disease
.



The formula is [TM score = (age * 0.
2) + 6 (atrial fibrillation) + 3 (hypertension) + 9 (facial paralysis) + 5 (NIHSS score >14)-6 (epilepsy)]
TM score table: the higher the TM score, the more support stroke is supported; The TM score ≤ 5 points, suggesting a high
probability of stroke mimetic disease.
The TM score of stroke simulation disease is mainly concentrated in 0-4 points; A TM score of ≥ 20 points has a predictive rate of more than
95% for acute cerebral infarction.


When the FABS score is 0-1 points, the prediction rate of stroke simulation disease is 0; When the FABS score is 5-6 points, the prediction rate of stroke simulation disease is 100%.

Therefore, the higher the FABS score, the more support is for stroke simulation disease
.

Treatment of SM

       

If there is a neurological deficit in the emergency department that cannot be distinguished as a result of stroke, such as head MRI is not available, the doctor should actively give RtPA thrombolytic therapy if it is within the time window, especially if posterior circulation stroke is
suspected.

Of course, the risk of bleeding from SM should also be alert and inform patients
.

Stroke mimes are common on the job, but most SMs can be ruled out
after careful history collection and physical examination, combined with multimodal imaging and laboratory tests if necessary.

Although the prognosis and thrombolytic prognosis of SM patients is relatively good, dizziness, headache, epilepsy, etc.
should also be fully evaluated by an experienced neurologist for diagnosis, and intravenous thrombolysis in SM patients should be reduced as much as possible to avoid unnecessary risks
.

References:

[1] Yang Jing, Indian Guard.
Stroke mimicry disease in the nervous system is rare.
Chinese Journal of Stroke.
2021,16(01).

[2] WU Jian,LIU Chenyu,MA Qingfeng.
Note the stroke mimic disease in venous thrombolysis.
Chinese Medical Journal.
2013,93(43).
[3] Alexander Polyak,William Frishman.
Myocardial Infarction With Nonobstructive Coronary Arteries.
Cardiol Rev.
2021,29(3):110-114.

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Source of this articleMedical Neurology ChannelThis article authorWang Lulu This article reviewLi Tuming Deputy Chief Physician
Responsible EditorLu Li Mr.
Xiang Yu

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