Einweisung von Nicht-Schlaganfallpatienten auf eine Stroke Unit

Code stroke: multicenter experience with in-hospital stroke alerts

Between 2.2% and 17% of all strokes have symptom onset during hospitalization in a patient originally admitted for another diagnosis or procedure. A response system to rapidly evaluate inpatients with acute neurologic symptoms facilitates evaluation and treatment of stroke developing during hospitalization. The National Stroke Association implemented an in-hospital stroke quality-improvement initiative from July 2010 to June 2011 in 6 certified stroke centers from Michigan, South Carolina, Pennsylvania, Colorado, Washington, and North Carolina. Three hundred ninety-three in-hospital stroke alerts were examined over a 1-year period. Of the alerts, 42.5% were for ischemic stroke, 8.7% probable or possible TIA, 2.8% intracranial hemorrhage, and 46.1% were stroke mimics. The most common stroke mimics were seizure, hypotension, and delirium. Participating hospitals had an alarm rate for diagnoses other than acute cerebrovascular events ranging from 28.0% to 66.7%. Of 194 in-hospital stroke/transient ischemic attack cases, 8.2% received intravenous thrombolysis alone, 10.3% received intra-arterial/mechanical thrombolysis alone, and 1% received both. No patient with a stroke mimic received thrombolysis. Our findings suggest that in-hospital response teams need to be prepared to respond to a range of acute medical conditions other than ischemic stroke.

Acute inferior homonymous quandrantanopia in a 71-year-old woman

A 71-year-old woman presented with acute inferior homonymous quadrantanopia initially mimicking acute ischemic stroke. As clinical signs and symptoms progressed to akinetic mutism with myoclonus the diagnosis of the Heidenhain variant of Creutzfeldt-Jakob disease was made. Brain MRI 4 days after symptom onset revealed ribbon-like high signal intensity in the medial occipital cortex.

Diagnostic yield of cerebral imaging in patients with acute confusion

OBJECTIVE

Acute confusion (AC) is a frequent reason for hospital admission in elderly patients. Although in majority of cases the cause is a systemic disorder (e.g., dehydration or septicaemia), patients are frequently subjected to cerebral imaging. This study was undertaken to find clinical predictors of normal cerebral computed tomography (CCT) or magnetic resonance imaging (MRI) scans in AC.

METHODS

Retrospective study of 294 patients admitted with AC of unknown origin, of whom 178 received cerebral imaging.

RESULTS

The rate of pathological imaging studies was 14%. The best single predictor of a normal brain scan was the absence of focal signs. Patients without focal abnormalities and either fever or dehydration had a probability of 0.96 of having a normal CCT or MRI. In demented patients without focal signs, the predictive value for a normal brain scan was 0.98, and if either patients with drowsiness were excluded or the existence of fever or dehydration was added as a selection criterion, all patients had normal scans.

CONCLUSIONS

Patients with AC without focal signs and with either evidence for a medical aetiology of delirium or prediagnosed dementia are at a very low risk of having focal lesions in their CCT or MRI.

Identification of nonischemic stroke mimics among 411 code strokes at the University of California, San Diego, Stroke Center

BACKGROUND

Code Stroke systems are widely used to expedite emergency treatment of patients with stroke. Code Stroke for mimic patients-those without a stroke cause-wastes resources. We investigated how many times a Code Stroke was initiated for patients who did not have a stroke appropriate for thrombolysis.

METHODS

We conducted a retrospective review of the discharge diagnoses of all patients who presented to our emergency department as a Code Stroke. A patient was considered a stroke mimic if a stroke code was activated, but none of the first 3 International Classification of Diseases, Ninth Revision codes on discharge were transient ischemic attack-related or ischemic stroke-related.

RESULTS

A total of 411 patients presented to the emergency department as Code Stroke. In all, 104 (25.3%) were discharged without a diagnosis of stroke or transient ischemic attack. The diagnoses in this group were intracranial hemorrhage in 19 patients, subarachnoid hemorrhage 6, subdural hematoma 3, old deficit 11, hypotension 11, seizure 10, intoxication 8, hypoglycemia 7, mass lesion 6, migraine 5, and other 18. In all, 33 of 307 eligible patients (10.7%) were treated with tissue-type plasminogen activator. None of the patients with a stroke mimic received tissue-type plasminogen activator. In 44 of 104 stroke mimics (42.3%), the acute disease was caused by a severe neurologic condition other than ischemic cerebrovascular disease. Only 60 of 411 stroke codes (14.6%) were initiated for patients without a severe and acute neurologic condition.

CONCLUSIONS

In our community, 25.5% of all Code Strokes were initiated for stroke mimics. Most mimic patients had an illness likely to benefit from urgent neurologic evaluation.

Prolongierte Migräneaura vs. akuter ischämischer Insult

BACKGROUND

According to the "time is brain" concept, differential diagnosis of acute stroke and prolonged migrainous aura is of vital importance in this era of systemic thrombolysis for acute cerebral ischemia. We demonstrate the value of cerebral magnetic resonance imaging (cMRI) in acute situations by presenting two patients.

PATIENTS AND METHODS

Two patients were sent to our hospital for lysis treatment after the sudden appearance of global aphasia and slight right-sided hemiparesis. Further exploration was impossible due to the aphasia, and therefore we performed diffusion- and perfusion-weighted cMRI.

RESULTS

We excluded acute cerebral infarction by the aid of diffusion-weighted cMRI, however left-sided cerebral hypoperfusion was seen in both patients. After resolution of neurologic symptoms, unilateral headache occurred and both patients reported pre-existing migraine with aura.

CONCLUSION

Hypoperfusion of the malfunctioning brain region contralateral to the affected side of the body has been described on cMRI in only a few patients with prolonged migrainous aura. We conclude from our two cases that--provided rapid availability--cMRI can add important information for differential diagnosis, in particular when lysis therapy is a treatment option.