Abstract

Retrospective Study

Stroke Mimics: Insights from a Retrospective Neuroimaging Study

Lucia Monti*, Davide del Roscio, Francesca Tutino, Tommaso Casseri, Umberto Arrigucci, Matteo Bellini, Maurizio Acampa, Sabina Bartalini, Carla Battisti, Giovanni Bova and Alessandro Rossi

Published: 27 September, 2023 | Volume 7 - Issue 2 | Pages: 094-103

Objectives: The study’s goals are to evaluate the management of Stroke Mimics (SMs), conditions with stroke-like symptoms but non-vascular origins. It seeks to avoid the unnecessary intravenous thrombolysis, the target therapy delays and determine the best SMs diagnosis approach.
Materials and methods: A review was conducted of all patients admitted to the Emergency Department under a “stroke code” from January 1, 2018, to January 31, 2019. Anamnestic and clinical data, along with information on neuroimaging protocols and findings, were collected. Advanced MRI sequences, such as Arterial Spin Labeling (ASL) MR perfusion and MR spectroscopy, were revised to confirm the diagnoses.
Results: 513 stroke codes were found; a neurovascular disease was diagnosed in 414 cases: 282 ischemic strokes and 73 intracranial hemorrages and 59 TIAs. The 99 SMs included, 13 infections, 12 syncopes, 11 epileptic seizures, 11 hemodinamic conditions, 10 tumors, 9 metabolic disorders, 9 diziness, 7 migraines, 4 drug/alcohol intoxication, 3 functional disorders, 3 acute hydrocefalus, 2 multiple sclerosis, 2 arteriovenous malformations, 1 spinal cord compression and 2 unexplained conditions. Specific neuroimaging findings were evaluated for all cases. Positive and negative predictive values of clinical diagnosis of SM were respectively 0.23 and 0.35. 125 SM patients underwent MRI examination, 40 of which within 3 hours from the activation of stroke code. Advanced MRI sequences as ASL, MR perfusion, MR spectroscopy were used to reach the correct diagnosis.
Conclusions: Advanced multimodal MRI can be a valuable tool in the assessment of, particularly in cases where conventional imaging techniques such as DWI-FLAIR mismatch are inconclusive. The novelty of this retrospective study is to demonstrate that the consistent use of arterial spin labeling perfusion in cases with stroke code leads to a rapid and accurate diagnosis of SMs. The implementation of an MRI-based pathway can expedite the diagnosis and treatment of underlying non-vascular causes such as SMs.

Read Full Article HTML DOI: 10.29328/journal.jnnd.1001083 Cite this Article Read Full Article PDF

Keywords:

Stroke mimic; Acute ischemic stroke; Arterial spin labeling; Advanced MRI; Brain perfusion

References

  1. Anathhanam S, Hassan A. Mimics and chameleons in stroke. Clin Med (Lond). 2017 Apr;17(2):156-160. doi: 10.7861/clinmedicine.17-2-156. PMID: 28365629; PMCID: PMC6297626.
  2. Zinkstok SM, Engelter ST, Gensicke H, Lyrer PA, Ringleb PA, Artto V, Putaala J, Haapaniemi E, Tatlisumak T, Chen Y, Leys D, Sarikaya H, Michel P, Odier C, Berrouschot J, Arnold M, Heldner MR, Zini A, Fioravanti V, Padjen V, Beslac-Bumbasirevic L, Pezzini A, Roos YB, Nederkoorn PJ. Safety of thrombolysis in stroke mimics: results from a multicenter cohort study. Stroke. 2013 Apr;44(4):1080-4. doi: 10.1161/STROKEAHA.111.000126. Epub 2013 Feb 26. PMID: 23444310.
  3. Liberman AL, Prabhakaran S. Stroke Chameleons and Stroke Mimics in the Emergency Department. Curr Neurol Neurosci Rep. 2017 Feb;17(2):15. doi: 10.1007/s11910-017-0727-0. PMID: 28229398.
  4. Quenardelle V, Lauer-Ober V, Zinchenko I, Bataillard M, Rouyer O, Beaujeux R, Pop R, Meyer N, Delplancq H, Kremer S, Marescaux C, Gény B, Wolff V. Stroke Mimics in a Stroke Care Pathway Based on MRI Screening. Cerebrovasc Dis. 2016;42(3-4):205-12. doi: 10.1159/000445956. Epub 2016 Apr 26. PMID: 27111336.
  5. Dawson A, Cloud GC, Pereira AC, Moynihan BJ. Stroke mimic diagnoses presenting to a hyperacute stroke unit. Clin Med (Lond). 2016 Oct;16(5):423-426. doi: 10.7861/clinmedicine.16-5-423. PMID: 27697802; PMCID: PMC6297311.
  6. Nau KC, Crocco T, Biola J, Larrabee H. Is it stroke, or something else? J Fam Pract. 2010 Jan;59(1):26-31. PMID: 20074498.
  7. Lehman LL, Danehy AR, Trenor CC 3rd, Calahan CF, Bernson-Leung ME, Robertson RL, Rivkin MJ. Transient Focal Neurologic Symptoms Correspond to Regional Cerebral Hypoperfusion by MRI: A Stroke Mimic in Children. AJNR Am J Neuroradiol. 2017 Nov;38(11):2199-2202. doi: 10.3174/ajnr.A5296. Epub 2017 Jul 13. PMID: 28705823; PMCID: PMC7963593.
  8. Allder SJ, Moody AR, Martel AL, Morgan PS, Delay GS, Gladman JR, Fentem P, Lennox GG. Limitations of clinical diagnosis in acute stroke. Lancet. 1999 Oct 30;354(9189):1523. doi: 10.1016/s0140-6736(99)04360-3. PMID: 10551501.
  9. Mair G, Wardlaw JM. Imaging of acute stroke prior to treatment: current practice and evolving techniques. Br J Radiol. 2014 Aug;87(1040):20140216. doi: 10.1259/bjr.20140216. Epub 2014 Jun 17. PMID: 24936980; PMCID: PMC4112390.
  10. Hodler J, Kubik-Huch RA, von Schulthess GK, editors. Diseases of the Brain, Head and Neck, Spine 2020–2023: Diagnostic Imaging [Internet]. Cham (CH): Springer; 2020. PMID: 32119229.
  11. Moulin S, Leys D. Stroke mimics and chameleons. Curr Opin Neurol. 2019 Feb;32(1):54-59. doi: 10.1097/WCO.0000000000000620. PMID: 30239360.
  12. Ay H, Buonanno FS, Rordorf G, Schaefer PW, Schwamm LH, Wu O, Gonzalez RG, Yamada K, Sorensen GA, Koroshetz WJ. Normal diffusion-weighted MRI during stroke-like deficits. Neurology. 1999 Jun 10;52(9):1784-92. doi: 10.1212/wnl.52.9.1784. PMID: 10371524.
  13. Vilela P. Acute stroke differential diagnosis: Stroke mimics. Eur J Radiol. 2017 Nov;96:133-144. doi: 10.1016/j.ejrad.2017.05.008. Epub 2017 May 5. PMID: 28551302.
  14. Liberman AL, Liotta EM, Caprio FZ, Ruff I, Maas MB, Bernstein RA, Khare R, Bergman D, Prabhakaran S. Do efforts to decrease door-to-needle time risk increasing stroke mimic treatment rates? Neurol Clin Pract. 2015 Jun;5(3):247-252. doi: 10.1212/CPJ.0000000000000122. PMID: 26124982; PMCID: PMC4469347.
  15. Kothari RU, Brott T, Broderick JP, Hamilton CA. Emergency physicians. Accuracy in the diagnosis of stroke. Stroke. 1995 Dec;26(12):2238-41. doi: 10.1161/01.str.26.12.2238. PMID: 7491643.
  16. Huff JS. Stroke mimics and chameleons. Emerg Med Clin North Am. 2002 Aug;20(3):583-95. doi: 10.1016/s0733-8627(02)00012-3. PMID: 12379962.
  17. Mathews MS, Smith WS, Wintermark M, Dillon WP, Binder DK. Local cortical hypoperfusion imaged with CT perfusion during postictal Todd's paresis. Neuroradiology. 2008 May;50(5):397-401. doi: 10.1007/s00234-008-0362-1. PMID: 18278489.
  18. Rupprecht S, Schwab M, Fitzek C, Witte OW, Terborg C, Hagemann G. Hemispheric hypoperfusion in postictal paresis mimics early brain ischemia. Epilepsy Res. 2010 May;89(2-3):355-9. doi: 10.1016/j.eplepsyres.2010.02.009. Epub 2010 Mar 16. PMID: 20236802.
  19. Van Cauwenberge MGA, Dekeyzer S, Nikoubashman O, Dafotakis M, Wiesmann M. Can perfusion CT unmask postictal stroke mimics? A case-control study of 133 patients. Neurology. 2018 Nov 13;91(20):e1918-e1927. doi: 10.1212/WNL.0000000000006501. Epub 2018 Oct 17. PMID: 30333164.
  20. Morgenstern LB, Frankowski RF. Brain tumor masquerading as stroke. J Neurooncol. 1999 Aug;44(1):47-52. doi: 10.1023/a:1006237421731. PMID: 10582668.
  21. Krishnaiah B, Ermak D. Anaplastic Astrocytoma Presenting as Ischemic Stroke: A Diagnostic Pitfall. Austin J Cerebrovasc Dis & Stroke. 2017; 4:1058.
  22. Friberg L, Olsen TS, Roland PE, Lassen NA. Focal ischaemia caused by instability of cerebrovascular tone during attacks of hemiplegic migraine. A regional cerebral blood flow study. Brain. 1987 Aug;110 (Pt 4):917-34. doi: 10.1093/brain/110.4.917. PMID: 3651801.
  23. Lindahl AJ, Allder S, Jefferson D, Allder S, Moody A, Martel A. Prolonged hemiplegic migraine associated with unilateral hyperperfusion on perfusion weighted magnetic resonance imaging. J Neurol Neurosurg Psychiatry. 2002 Aug;73(2):202-3. doi: 10.1136/jnnp.73.2.202. PMID: 12122185; PMCID: PMC1737998.
  24. Sugita Y, Koyanagi M, Oda M, Kobayashi T, Narumi O, Saiki M. Severe Hypoglycemia-induced Right Hemiparesis with Reversible Diffusion Restriction in the Left Internal Capsule Due to Combination Therapy Using Disopyramide and Clarithromycin. NMC Case Rep J. 2017 Nov 21;5(1):31-33. doi: 10.2176/nmccrj.cr.2017-0045. PMID: 29354336; PMCID: PMC5767484.
  25. Yoshino T, Meguro S, Soeda Y, Itoh A, Kawai T, Itoh H. A case of hypoglycemic hemiparesis and literature review. Ups J Med Sci. 2012 Aug;117(3):347-51. doi: 10.3109/03009734.2011.652748. Epub 2012 Jan 17. PMID: 22247979; PMCID: PMC3410296.
  26. Morello A, Casseri T, Acampa M, Galluzzi P, Cerase A, Monti L. Stroke in Pregnancy and Review of Current Literature: Arterial Spin-Labeling MRI Can Identify the Presence and Intensity of Collateral Circle. J Stroke Cerebrovasc Dis. 2018 Dec;27(12):3575-3577. doi: 10.1016/j.jstrokecerebrovasdis.2018.08.027. Epub 2018 Sep 15. PMID: 30228010.
  27. Haller S, Zaharchuk G, Thomas DL, Lovblad KO, Barkhof F, Golay X. Arterial Spin Labeling Perfusion of the Brain: Emerging Clinical Applications. Radiology. 2016 Nov;281(2):337-356. doi: 10.1148/radiol.2016150789. PMID: 27755938.
  28. Ferré JC, Bannier E, Raoult H, Mineur G, Carsin-Nicol B, Gauvrit JY. Arterial spin labeling (ASL) perfusion: techniques and clinical use. Diagn Interv Imaging. 2013 Dec;94(12):1211-23. doi: 10.1016/j.diii.2013.06.010. Epub 2013 Jul 11. PMID: 23850321.

Figures:

Figure 1

Figure 1

Figure 1

Figure 2

Figure 1

Figure 3

Figure 1

Figure 4

Figure 1

Figure 5

Figure 1

Figure 6

Figure 1

Figure 7

Similar Articles

  • Analysis of early Versus Delayed Carotid Surgery after Acute Ischemic Stroke
    PEROU Sébastien*, DETANTE Olivier, SPEAR Rafaelle, PIRVU Augustin, ELIE Amandine and MAGNE Jean-Luc PEROU Sébastien*,DETANTE Olivier,SPEAR Rafaelle,PIRVU Augustin,ELIE Amandine,MAGNE Jean-Luc. Analysis of early Versus Delayed Carotid Surgery after Acute Ischemic Stroke. . 2017 doi: 10.29328/journal.jnnd.1001001; 1: 001-011
  • Endovascular treatment experience in acute ischemic stroke
    İbrahim Acır*, Vildan Yayla and Hacı Ali Erdoğan İbrahim Acır*,Vildan Yayla,Hacı Ali Erdoğan. Endovascular treatment experience in acute ischemic stroke. . 2021 doi: 10.29328/journal.jnnd.1001047; 5: 026-028
  • Endovascular management of tandem occlusions in stroke: Treatment strategies in a real-world scenario
    Juan J Cirio*, Celina Ciardi, Matias Lopez, Esteban V Scrivano, Javier Lundquist, Ivan Lylyk, Nicolas Perez and Pedro Lylyk Juan J Cirio*,Celina Ciardi,Matias Lopez,Esteban V Scrivano,Javier Lundquist,Ivan Lylyk,Nicolas Perez,Pedro Lylyk. Endovascular management of tandem occlusions in stroke: Treatment strategies in a real-world scenario. . 2021 doi: 10.29328/journal.jnnd.1001051; 5: 055-060
  • Stroke Mimics: Insights from a Retrospective Neuroimaging Study
    Lucia Monti*, Davide del Roscio, Francesca Tutino, Tommaso Casseri, Umberto Arrigucci, Matteo Bellini, Maurizio Acampa, Sabina Bartalini, Carla Battisti, Giovanni Bova and Alessandro Rossi Lucia Monti*, Davide del Roscio, Francesca Tutino, Tommaso Casseri, Umberto Arrigucci, Matteo Bellini, Maurizio Acampa, Sabina Bartalini, Carla Battisti, Giovanni Bova, Alessandro Rossi. Stroke Mimics: Insights from a Retrospective Neuroimaging Study. . 2023 doi: 10.29328/journal.jnnd.1001083; 7: 094-103

Recently Viewed

Read More

Most Viewed

Read More

Help ?