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Stroke Mimics Stroke Mimics 16.10.2019 Stroke Mimics Stroke Mimics Carolina Tramontini, M.D. Neuroradiologist Clínica Universitaria Colombia, Bogotá Disclosure: I have nothing to disclose Neuroradiology Professor Fundación Universitaria Sanitas, Bogotá ECNR Rovinj, October 16th, 2019 Stroke Mimics Stroke Mimics • Introduction • Introduction • Topographic distribution patterns • Topographic distribution patterns • Imaging approach in stroke mimics • Imaging approach in stroke mimics • Take home messages • Take home messages Introduction Introduction • Stroke is a clinical diagnosis • For the clinician it is not always an easy Dx • Stroke mimics in – 9‐31% of suspected strokes Two different types of diagnostic error – 2.8‐17% of strokes treated with IV‐tPA • Many different causes Presentations sugesting • Imaging facilitates diagnosis Conditions resembling stroke another condition but are but are no real stroke stroke • But brain imaging, even DWI, are not infallible STROKE MIMICS STROKE CHAMELEON Kamalian S et all. Applied Radiology, 2015 Dupre et all, J Stroke Cerebrovasc Dis, 2017 Hand PJ et all. Stroke, 2006 Boulter TJ,Schaeffer PW, Seminars in Radiology 2014 Boulter TJ,Schaeffer PW, Seminars in Radiology 2014 1 16.10.2019 Predictor for Stroke and Mimics Causes of stroke Mimics Stroke Mimic predictors predictors Most frequent causes are: Seizure 21%‐ 17% • Exact time of onset • Cognitive impairment • Definite focal symptoms • Abnormal signs in other Sepsis 17%‐13% • Abnormal vascular findings systems • Presence of neurological signs • Loss of consciousness or Toxic/metabolic 13%‐ 11% • seizures at onset Being able to lateralize the signs Space occupying lesions 15%‐9% to left or right side of the brain • Complete abscence of • Being able to determine a neurological signs Syncope 9% clinical stroke subclassification Hand PJ et all. Stroke, 2006 Kamalian S et all. Applied Radiology, 2015 Liberman AL, Prabhakaran S. Curr Neurol Neurosci Rep 2017 Hand PJ et all. Stroke, 2006. Causes of stroke Mimics Stroke Mimics and Thrombolysis • 57% of mimics were neurological conditions • Stroke mimics account for 2 to 17% of Iv‐tPA treated patients • In +18% of mimics neurological conditions were in the DDX • Incidence of sICH – Stroke mimics 0.5‐ 1% • • 75% of mimics with 42% of mimics had – Confirmed stroke patients 4‐ 7.9% neurological conditions previous stroke • Median excess cost was approximately US$ 5400 per admission Many had normal brain Most had abnormal imaging brain imaging “The benefit of rapid treatment with tPA likely outweighs the minimal risk of complications associated with tPA in stroke mimics” Liberman AL, Prabhakaran S. Curr Neurol Neurosci Rep 2017 Daniere F et all. Journal of Neuroradiology 2014 Hand PJ et all. Stroke, 2006. Goyal N, Journal of Stroke and Cerebrovascular Diseases, 2015 Zinkstok SM et all, Stroke 2013 Stroke Mimics Approach based on topographic distribution patterns Large artery territory Regional grey and white infarction matter Deep grey matter and Perforating vessel infarction • Introduction brain stem Vascular watershed • Topographic distribution patterns Border zone pattern border zones • Imaging approach in stroke mimics Hypoxic ischemic Cortical and deep gray • Take home messages encephalopathy matter Ischemic white matter White matter disease Central embolization Scattered foci 2 16.10.2019 Approach based on topographic Regional grey and white matter distribution patterns Large artery territory infarct Seizures • Regional grey and white matter Migraine • Cortical and deep gray matter Brain tumors • Deep grey matter Herpes simplex encephalitis • White matter Hypoglicemia • Scattered foci Transient global amnesia • Border zone pattern MELAS Venous infarctions Regional grey and white matter Seizures Seizures • One‐third of stroke mimics are due to seizures or postictal deficits • Seizures may cause T2 hyperintensity and restricted diffusion • Distinguishing features – Nonvascular distribution – Earlier edema and gyral enhancement – Normal or elevated perfusion Three patterns of diffusion restriction: – Absence of vascular occlusion • Hypocampus: Ipsilateral to side of seizure onset – Sometimes simultaneous restricted cortical and elevated subcortical • Cortical: Hypoxia, reduced energy suply, cytotoxic edema diffusion Boulter TJ,Schaeffer PW, Seminars in Radiology 2014 • Splenial: excitotoxic damage due to status epilepticus Milligan T et all, Seizure 2009 Daniere F et all, Journal of Neuroradiology, 2014 Milligan T et all, Seizure 2009 Regional grey and white matter Regional grey and white matter Migraine Brain tumors • Causes 5‐10% of stroke mimics • May present with acute neurologic deficits • May show restricted diffusion • Low‐grade glial tumor • Distinguishing factors – Mild mass effect – Long history of migraines – Cortical involvement – Involvement of multiple arterial territories – May be confused with subacute infarction – Absence of vascular occlusion • High‐grade gliomas with hemorrhage • Perfusion decreases in acute‐onset aura – Can show areas of restricted diffusion • Perfusion is normal or elevated in prolonged episodes – Heterogeneous enhancement • The lesions are usually reversible – Mass effect – May be confused with subacute infarction But remember : 15% of strokes in patients younger than 45 years of age are due to migraine 3 16.10.2019 Brain tumors Brain tumors Distinguishing features Nonvascular distribution Lack of significant restricted diffusion Lack of gyral enhancement Regional grey and white matter Herpes simplex encephalitis Herpes simplex encephalitis • Most common cause of viral encephalitis • Predilection for the limbic system • Restricted diffusion is observed in early stages Irreversible neuronal damage • Hyperintense on FLAIR images • Cause of restricted diffusion: glutamate excitotoxic pathway • Frequently hemorrhagic transformation • DWI shows concurrent areas with decreased Kamalian S et all. Applied Radiology, 2015 and increased diffusivity Boulter TJ,Schaeffer PW, Seminars in Radiology 2014 Regional grey and white matter Hypoglicemia Hypoglicemia • Can present with focal neurologic deficits • Restricted diffusion may be seen in the cerebral cortex (occipital lobes), corona radiata and centrum semiovale • Basal ganglia, hippocampi, internal capsules and splenium may be involved • Cerebellum, brain stem and hypothalamus are usually spared Kang, AJNR, 2010 4 16.10.2019 Hypoglicemia Cortical and deep gray matter Hypoxic‐ischemic encephalopathy Wernicke’s encephalopathy Cause of diffusion restriction: Hepatic encephalopathy Creutzfeldt‐Jakob disease Energy failure due to lack of glucose Excitotoxic edema Eastern equine encephalitis Asymmetric cerebral blood flow Cortical and deep gray matter Wernicke’s encephalopathy Wernicke’s encephalopathy • In alcoholics and other malnourished patients with thiamine deficiency • Clinically presents with: – Altered mental status – Memory impairment – Ophthalmoplegia Symmetric T2/FLAIR hyperintensity in : • Mammillary bodies – Ataxia • Hypothalami • Medial thalami • Tectal plate and periaqueductal area • Cerebral cortex may also be involved Wernicke’s encephalopathy Wernicke’s encephalopathy • Early stages: restricted diffusion due to cytotoxic edema • Later stages: no diffusion restriction 5 16.10.2019 Cortical and deep gray matter Hepatic encephalopathy Hepatic encephalopathy • Neuropsychiatric abnormalities, potentially reversible • In chronic and acute hepatic failure • Clinical severity: West Haven Criteria grades 1‐4 • Diffuse cortical involvement can be reversible, but is associated with an increased risk of permanent neurologic sequela • Decrease in ADC values due to the excitotoxic injury and osmotic disturbance in astrocytes due to ammonia Mild case: symmetric T1 McKinney et all AJNR 2010 hyperintensity in globus pallidus Rovira et all AJNR 2008 Hepatic encephalopathy Cortical and deep gray matter Creutzfeldt‐Jakob disease • Transmissible and fatal neurodegenerative disease caused by a misfolded prion protein • Sporadic, familiar and acquired (iatrogenic and variant) forms • Patients present with a rapidly progressive dementia • Involvement of the basal ganglia (symmetric) Case courtesy: Fabricio Goncalvez • Involvement of the cortex (symmetric or assymetric) Severe case: T2 hyperintensity and restricted diffusion • DWI is more sensitive than FLAIR orT2WI in the cortex (especially the cingulate gyri and insula), • Decreased ADC McKinney et all AJNR 2010 Wada R, Kucharczyk W. Neuroimag Clin 2008 basal ganglia, and thalami Rovira et all AJNR 2008 Boulter TJ, Schaeffer PW. Seminars in Radiology 2014 Creutzfeldt‐Jakob disease Deep gray matter Perforating vessel infarction Carbon monoxide poisoning Osmotic demyelination syndrome Vigabatrin toxicity Nonketotic hyperglycemia Sporadic CJD • EEG with period sharp wave complexes • 14‐3‐3 protein positive in CSF • sCJD has not pulvinar and hockey stick signs seen in vCJD Radiology Assistant.com 6 16.10.2019 Deep gray matter Carbon monoxide poisoning Carbon monoxide poisoning Basal ganglia, thalami Restricted diffusion GP Severe Cerebral cortex and wm Mild T2 hyperintense GP Corpus callosum • Delayed encephalopathy : – Bilateral confluent periventricular white matterT2 hyperintensity – Areas of restricted diffusion • Restricted diffusion – Acute phase : cytotoxic edema – Delayed phase: demyelination Deep gray matter Osmotic demyelination syndrome Osmotic demyelination syndrome • Due to rapid correction of hyponatremia • Can be seen with malnourishment, chronic alcoholism, hyperosmolar conditions,
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