Do you know that these 6 diseases may be misdiagnosed as stroke?

Introduction: Simulated stroke disease (SM) refers to a large group of diseases in which the patient's clinical symptoms and signs are similar to stroke at the beginning of the disease.
After detailed medical history inquiry, examination, evaluation and follow-up, it is finally confirmed that the patient is not a stroke.
｡SM because its clinical symptoms and signs are similar to strokes, it is easy to cause misdiagnosis and mistreatment by neurologists or emergency physicians.
This article combines actual cases and summarizes 6 common SMs in order to help clinicians.

Yimaitong compiles and organizes, please do not reprint without authorization.

01 Seizures Seizures are one of the most common SM, especially in patients with Todd's palsy or paroxysmal aphasia/dysphagia.

Epilepsy-related cortical signal abnormalities may be related to abnormal DWI.

The distinguishing features of arterial infarction include avascular distribution, gyrus or pia mater enhancement, and avascular occlusion.

Signal changes are usually reversible, but may develop into cortical necrosis or focal atrophy.

The epileptic area may have mild hyperperfusion or normal.

 02 Migraine Such patients usually have a history of typical migraine, and may have headaches, photophobia and other auras.
The first attack of hemiplegic migraine is usually around 45 years old or older.
Such attacks are often confused with TIA.
It is treated as a stroke treatment.
Neuroimaging in these patients is usually normal, but limited spread may be rare.

Abnormal perfusion is more common in these cases, usually underperfusion at the beginning and sometimes high perfusion afterwards.

It is important to note that, in contrast to the hypoperfusion of a single vessel area in acute infarction, this type of disease usually affects multiple vessel areas.

 03 Tumor Patients with tumors may suddenly have "stroke-like" symptoms.

It is important to recognize this not only to avoid unnecessary thrombolytic therapy, but also to not delay the identification and treatment of brain tumors.

When the tumor is small, located in the cortex, and the arterial distribution has different enhancement patterns (Figure 1-Case 1), misdiagnosis often occurs.

In addition, DWI can show different signal characteristics, depending on the characteristics of tumor cells.

Perfusion may be helpful, especially the increased perfusion of gliomas, including increased cerebral blood volume (CBV) (compared to the low CBV expected in acute infarction).

Figure 1 SM: Tumor.

Case 1: This 83-year-old woman went to the hospital due to dysarthria.

CT of emergency stroke showed focal lesions on the left side, cortical curve enhanced, blood volume and blood flow increased focally (white arrow), and showed normal to rapid perfusion transit time.

Accompanied by enhanced gyration and "luxury perfusion" is considered a subacute infarction.

As the symptoms progressed, a follow-up MRI after 1 month showed that the expansion heterogeneity of the lesions increased, and the pathologically confirmed glioblastoma.

04 Venous infarction Cerebral venous thrombosis is a life-threatening neurological disease that cannot be ignored.

Compared with arterial infarction, venous infarction has different distribution characteristics, mainly depending on the location of venous thrombosis, but usually lacks arterial distribution.

DWI abnormalities are variable in venous infarction.

Venous infarction may also show flame-like bleeding.

CT angiography (CTA) can help confirm localized obstruction or diffuse atherosclerosis (Figure 2-Case 2).
This method has an ischemic stroke recognition probability of OR=23.
6.
CTA increases its sensitivity by more than 70 %, and the specificity is close to 88%.
However, CTA is not widely used in emergency department due to the lack of examination time and patient conditions.
The MR signal changes according to the age of the thrombus.

Cortical vein thrombosis may be accompanied by focal convex subarachnoid hemorrhage, which can be observed on gradient echo T2* or susceptibility-weighted sequences.

 Figure 2 Arterial SM: venous infarction.

Case 2: A 48-year-old female with a headache for 2 days, accompanied by sudden paresthesias in her left arm.

Emergency non-enhanced CT showed heterogeneous density and swelling of the right parietal lobe, showing linear intrathecal density, suggesting subarachnoid blood.

CT perfusion is symmetrical, and CTA is normal initially.

As the condition worsened, MRI examination was performed 6 hours later, showing signs of bilateral hemorrhagic venous infarction, thrombotic superior sagittal sinus and cortical vein thrombosis (white arrow), and corresponding dural sinus filling on the image after contrast Defect (red arrow).

To recap, in the initial coronal and sagittal CTA reconstruction, there was an "empty δ" symbol in the sagittal sinus, but it was missed due to rush.

 05 Reversible posterior encephalopathy syndrome (PRES) PRES is an under-recognized syndrome in the emergency room.
It mainly manifests as headaches, seizures, changes in mental status, and changes or loss of vision.

It is a clinical imaging diagnosis characterized by a transient failure of vascular autoregulation leading to multifocal angiogenic edema.

Patients with malignant hypertension, eclampsia, chemotherapy or taking post-transplant drugs seem to be particularly susceptible.

Usually PRES lesions are bilateral, subcortical, non-enhancing, and mainly involve the parieto-occipital area.

PRES rarely manifests as posterior fossa involvement, limited spread, enhancement, and bleeding (Figure 3-Case 3).

Figure 3 SM: PRES.

Case 3: A 55-year-old patient presented with acute headache and visual impairment.
MRI showed abnormal bilateral symmetrical signals, which was consistent with parietooccipital vasogenic edema and showed typical PRES-like images.

The pia mater is hyperemic but the parenchymal enhancement is not abnormal, and only small lesions have limited spread.

The abnormal FLAIR signal disappeared after 4 weeks of follow-up.

 06 Subdural hematoma Patients with subacute to chronic subdural hematoma may show clinical symptoms of stroke, including stroke, ataxia, and hemiplegia.

In view of their characteristic imaging, they can be easily identified on CT and MRI (see Figure 4-case 4).

 Figure 4 SM: Subdural hematoma, diagnosed by rapid screening MRI scheme.

Case 4: A 58-year-old man suddenly developed hemiplegia and coma on his left body.

Fearing about occlusion of the right MCA, emergency physicians quickly transferred the patient to the stroke emergency center.

A non-contrast rapid screening MRI program (including normal MRA-MRV, not shown) was obtained in an imaging time of <7 minutes.

An accidental right convex subdural hematoma caused a mass effect at the frontal-parietal junction.

The high intensity signal of T1 is mainly consistent with methemoglobin, and the lesion (arrow) on T2* indicates acute intracellular components.

In addition, other diseases that mimic acute arterial ischemic stroke include infections (encephalitis, abscesses, meningitis, sepsis), metabolic abnormalities (hypoglycemia, hepatic encephalopathy), demyelinating diseases, and MELAS (mitochondrial encephalopathy, lactic acid Acidosis).

Emergency and neurologists must understand these SMs and minimize false or delayed diagnoses.

 Summary Although misdiagnosis can never be completely eliminated, we should be proficient in the higher incidence of SM.
For patients with suspected stroke within the time window, we should weigh the benefits of early thrombolysis and the risk of intracranial hemorrhage.
To identify all SM and do too many examinations, the current evidence shows that acute thrombolytic therapy is more beneficial to patients, especially young patients.
Therefore, clinicians must hone their sharp eyes on the one hand, and on the other We must also find a balance between rapid diagnosis and correct diagnosis.

 References: [1] Hodler J, Kubik-Huch RA, von Schulthess GK.
SourceDiseases of theBrain, Head and Neck, Spine 2020–2023: Diagnostic Imaging [Internet].
Cham(CH): Springer; 2020.
Chapter 3.
[ 2] Zhang Yi, Han Yanfei, Dong Wei, et al.
Common stroke simulation diseases and their differentiation from emergency stroke[J].
Journal of Clinical Neurology,2018,31(6):472-473.
[3] LibermanA L , Prabhakaran S.
Stroke Chameleons and Stroke Mimics in the Emergency Department[J].
Current Neurology & Neuroscience Reports, 2017, 17(2):15.
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