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Brachial Artery Embolus Mimicking Acute Stroke Christine Holmstedt and Marc Chimowitz Neurology 2011;76;E86-E87 DOI 10.1212/WNL.0B013e3182190cc0

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Brachial Artery Embolus Mimicking Acute Stroke Christine Holmstedt and Marc Chimowitz Neurology 2011;76;E86-E87 DOI 10.1212/WNL.0B013e3182190cc0 RESIDENT & FELLOW SECTION E-Pearl: Section Editor Brachial artery embolus mimicking acute Mitchell S.V. Elkind, MD, MS stroke Christine Holmstedt, DO PEARL paroxysmal atrial fibrillation, hypertension, dyslipi- Marc Chimowitz, • Limb arterial embolism should be considered in demia, congestive heart failure, and coronary artery MBChB the differential diagnosis of acute monoparesis disease. The patient was not anticoagulated because because the diagnosis may be missed if the of a recent gastrointestinal bleeding episode. other typical manifestations of this presentation The emergency department physician diagnosed Address correspondence and (pain, pallor, pulselessness, sensory loss, and acute stroke and requested a telemedicine consulta- reprint requests to Dr. Christine tion. The patient’s blood pressure was 160/70 mm Holmstedt, Harborview Office coolness of the arm) are overlooked. Although Tower, 19 Hagwood Ave., MSC the rapid identification of acute ischemic stroke Hg, and a rhythm strip demonstrated normal sinus 805, Medical University of South rhythm at 80 beats per minute. On neurologic exam- Carolina, Charleston, SC 29464 is essential to the timely delivery of thrombolyt- [email protected] ics, care must be taken to obtain the relevant ination, the right upper extremity strength revealed history and to ensure that important signs are no effort against gravity with some preserved not missed whether the evaluation of the pa- strength in wrist and finger extension. The patient tient is done at the bedside or by telemedicine. could not localize touch on the right arm. Findings • Rapid and accurate diagnosis of ischemic stroke from the remainder of the neurologic examination, is essential for timely and appropriate treatment including speech and language, cranial nerves, coor- with thrombolytic therapy. Occasionally, pa- dination, and right lower extremity strength and sen- tients who present with acute stroke mimics sation, were normal. Reflexes and plantar responses (i.e., disorders that resemble stroke such as sei- were not tested as part of the telemedicine stroke ex- zure, hypoglycemia, and psychogenic disorder) amination in this patient. A CT scan of the brain are incorrectly treated with thrombolytic ther- showed normal results. apy. The incidence of stroke mimics varies Because pain was a prominent feature of the pre- greatly and is dependent on many variables in- sentation, palpation of the right upper extremity for cluding time of evaluation and experience of pulses was suggested to the emergency department first responder.1 To our knowledge, the litera- physician. The right brachial and radial pulses were ture pertaining to stroke mimics or misdiagno- not palpable, and the right upper extremity was sis does not include limb ischemia due to colder than the left upper extremity. An emergency extremity embolism.2,3 We present a case of a right upper extremity ultrasound was performed, patient with acute right upper extremity weak- which revealed a right brachial artery occlusion. In- ness, who was referred through a stroke tele- travenous heparin treatment was started, and the pa- medicine evaluation system from a distant tient was transferred to the operating room for emergency department. History and examina- emergency right upper extremity exploration and tion by telemedicine led to the diagnosis of a embolectomy of the right brachial artery. right brachial artery embolus rather than a A transthoracic echocardiogram was negative for an stroke, which resulted in emergency surgical intracardiac thrombus. The patient recovered and was embolectomy rather than IV thrombolytic discharged home 3 days later with aspirin therapy. therapy. DISCUSSION This patient illustrates that brachial ar- CASE REPORT An 85-year-old woman presented tery embolism should be considered in the differential to an emergency department with acute onset of diagnosis of paresis of the arm and that the diagnosis right upper extremity pain and weakness. She denied may be missed if the other typical manifestations of this sitting with her arm propped up or falling asleep in presentation (pain, pallor, pulselessness, sensory loss, an unusual position. Her medical history included and coolness of the arm) are overlooked. The upper From the Stroke Program, Department of Neurosciences, Medical University of South Carolina, Charleston. Disclosure: Author disclosures are provided at the end of the article. e86 Copyright © 2011 by AAN Enterprises, Inc. extremity embolus was not suspected in this patient un- thrombolytic therapy, which may have been effective til the vascular neurologist obtained the history of pain, if the embolus was completely lysed. However, if the an uncommon presenting symptom of acute stroke. embolus had not lysed or was only partially lysed, This additional information prompted a peripheral vas- this may have been interpreted as a failure of throm- cular examination and ultimately an upper extremity bolysis for acute stroke. In this patient, failure to rec- ultrasound. ognize the brachial artery embolus could have Atrial fibrillation is thought to cause 80% of cases resulted in further limb ischemia, gangrene, limb of arterial embolic occlusion.4 Upper extremity em- amputation, or death. Even if the brachial artery bolic occlusions represent approximately 23% of all embolus had been recognized after unsuccessful peripheral limb emboli, with 61% occurring in the thrombolysis, the use of recombinant tissue-type plas- brachial artery.4 Symptoms of upper extremity arte- minogen activator may have necessitated delay of anti- rial occlusion generally consist of pallor, pain, and coagulation and embolectomy in an otherwise good paresthesias as well as a lack of brachial ulnar or radial surgical candidate. pulses. Other manifestations including weakness, Although the rapid identification of acute ischemic edema, distal limb rigidity, and anesthesia, which are stroke is essential to the timely delivery of thrombolyt- believed to reflect secondary thrombosis or multiple ics, care must be exercised to obtain a complete history emboli, are considered important prognostic factors.4 and perform a rapid and thorough examination. Our Historically, treatment of upper extremity embolism case not only represents an unusual stroke mimic but was conservative because the event was viewed as also reiterates the importance of fundamental clinic somewhat benign. However, in 1981, Haimovici4 skills in the evaluation of patients. described a series of 46 nonsurgically treated patients with upper extremity embolism of whom 31% devel- DISCLOSURE oped gangrene, had a hand amputation, or died. In a Dr. Chimowitz has served on scientific advisory boards for Gore Corpora- tion and Parexel; serves on the editorial board of Neurosurgery; has re- review of 322 cases of arterial embolectomy from 6 ceived research support from Boston Scientific, AstraZeneca, and the reports, 9.3% of patients developed gangrene and NIH/NINDS; and has served as an expert witness in medicolegal cases. 11.8% died. Dr. Holmstedt reports no disclosures. Current treatment recommendations include im- REFERENCES mediate anticoagulation with heparin, surgical em- 1. Vroomen PC, Buddingh MK, Luijckx GJ, De Keyser J. bolectomy, or intra-arterial thrombolytics and The incidence of stroke mimics among stroke department embolization. Randomized trials have suggested a admissions in relation to age group. J Stroke Cerebrovasc benefit of thrombolytic therapy in the initial man- Dis 2008;17:418–422. agement of patients with peripheral arterial occlu- 2. Nor AM, Ford GA. Misdiagnosis of stroke. Expert Rev Neurother 2007;7:989–1001. sion.5,6 Although limb salvage rates are similar 3. Hand PJ, Kwan J, Lindley RI, Dennis MS, Wardlaw JM. between the thrombolytic and open embolectomy Distinguishing between stroke and mimic at the bedside: groups, the survival rate was improved in the patients the brain attack study. Stroke 2006;37:769–775. randomized to the thrombolytic group.6 Regardless 4. Haimovici H. Cardiogenic embolism of the upper extrem- of management, prompt treatment is warranted be- ity. J Cardiovasc Surg 1982;23:209–213. cause arm ischemia can lead to loss of arm or hand 5. Ouriel K. Thrombolytic therapy for acute arterial occlu- sion. Curr Opin Gen Surg 1994:257–264. function. 6. Ouriel K, Shortell CK, DeWeese JA, et al. A comparison With regard to the case presented, several possible of thrombolytic therapy with operative revascularization in outcome scenarios existed. A misdiagnosis of acute the initial treatment of acute peripheral arterial ischemia. ischemic stroke may have led to treatment with IV J Vasc Surg 1994;19:1021–1030. Neurology 76 May 3, 2011 e87 E-Pearl: Brachial artery embolus mimicking acute stroke Christine Holmstedt and Marc Chimowitz Neurology 2011;76;e86-e87 DOI 10.1212/WNL.0b013e3182190cc0 This information is current as of May 2, 2011 Updated Information & including high resolution figures, can be found at: Services http://n.neurology.org/content/76/18/e86.full References This article cites 5 articles, 1 of which you can access for free at: http://n.neurology.org/content/76/18/e86.full#ref-list-1 Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): All Cerebrovascular disease/Stroke http://n.neurology.org/cgi/collection/all_cerebrovascular_disease_strok e Cardiac http://n.neurology.org/cgi/collection/cardiac Embolism http://n.neurology.org/cgi/collection/embolism Infarction http://n.neurology.org/cgi/collection/infarction
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