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Pinoșanu EA, Pîrșcoveanu D, Albu CV, Burada E, Pîrvu A, Surugiu R, Sandu RE, Serb AF. Rhoa/ROCK, mTOR and Secretome-Based Treatments for Ischemic Stroke: New Perspectives. Curr Issues Mol Biol 2024; 46:3484-3501. [PMID: 38666949 PMCID: PMC11049286 DOI: 10.3390/cimb46040219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Ischemic stroke triggers a complex cascade of cellular and molecular events leading to neuronal damage and tissue injury. This review explores the potential therapeutic avenues targeting cellular signaling pathways implicated in stroke pathophysiology. Specifically, it focuses on the articles that highlight the roles of RhoA/ROCK and mTOR signaling pathways in ischemic brain injury and their therapeutic implications. The RhoA/ROCK pathway modulates various cellular processes, including cytoskeletal dynamics and inflammation, while mTOR signaling regulates cell growth, proliferation, and autophagy. Preclinical studies have demonstrated the neuroprotective effects of targeting these pathways in stroke models, offering insights into potential treatment strategies. However, challenges such as off-target effects and the need for tissue-specific targeting remain. Furthermore, emerging evidence suggests the therapeutic potential of MSC secretome in stroke treatment, highlighting the importance of exploring alternative approaches. Future research directions include elucidating the precise mechanisms of action, optimizing treatment protocols, and translating preclinical findings into clinical practice for improved stroke outcomes.
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Affiliation(s)
- Elena Anca Pinoșanu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania; (E.A.P.); (D.P.); (C.V.A.)
- Doctoral School, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania
| | - Denisa Pîrșcoveanu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania; (E.A.P.); (D.P.); (C.V.A.)
| | - Carmen Valeria Albu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania; (E.A.P.); (D.P.); (C.V.A.)
| | - Emilia Burada
- Department of Physiology, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania;
| | - Andrei Pîrvu
- Dolj County Regional Centre of Medical Genetics, Clinical Emergency County Hospital Craiova, St. Tabaci, No. 1, 200642 Craiova, Romania;
| | - Roxana Surugiu
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania;
| | - Raluca Elena Sandu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania; (E.A.P.); (D.P.); (C.V.A.)
- Department of Biochemistry, University of Medicine and Pharmacy of Craiova, St. Petru Rares, No. 2-4, 200433 Craiova, Romania;
| | - Alina Florina Serb
- Department of Biochemistry and Pharmacology, Biochemistry Discipline, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Sq., No. 2, 300041 Timisoara, Romania;
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Abedi V, Misra D, Chaudhary D, Avula V, Schirmer CM, Li J, Zand R. Machine Learning-Based Prediction of Stroke in Emergency Departments. Ther Adv Neurol Disord 2024; 17:17562864241239108. [PMID: 38572394 PMCID: PMC10989051 DOI: 10.1177/17562864241239108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/07/2024] [Indexed: 04/05/2024] Open
Abstract
Background Stroke misdiagnosis, associated with poor outcomes, is estimated to occur in 9% of all stroke patients. Objectives We hypothesized that machine learning (ML) could assist in the diagnosis of ischemic stroke in emergency departments (EDs). Design The study was conducted and reported according to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis guidelines. We performed model development and prospective temporal validation, using data from pre- and post-COVID periods; we also performed a case study on a small cohort of previously misdiagnosed stroke patients. Methods We used structured and unstructured electronic health records (EHRs) of 56,452 patient encounters from 13 hospitals in Pennsylvania, from September 2003 to January 2021. ML pipelines, including natural language processing, were created using pre-event clinical data and provider notes in the EDs. Results Using pre-event information, our model's area under the receiver operating characteristics curve (AUROC) ranged from 0.88 to 0.92 with a similar range accuracy (0.87-0.90). Using provider notes, we identified five models that reached a balanced performance in terms of AUROC, sensitivity, and specificity. Model AUROC ranged from 0.93 to 0.99. Model sensitivity and specificity reached 0.90 and 0.99, respectively. Four of the top five performing models were based on the post-COVID provider notes; however, no performance difference between models tested on pre- and post-COVID was observed. Conclusion This study leveraged pre-event and at-encounter level EHR for stroke prediction. The results indicate that available clinical information can be used for building EHR-based stroke prediction models and ED stroke alert systems.
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Affiliation(s)
- Vida Abedi
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA
| | - Debdipto Misra
- Division of Informatics, Geisinger Health System, Danville, PA, USA
| | - Durgesh Chaudhary
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA, USA
- Department of Neurology, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Venkatesh Avula
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA
| | - Clemens M. Schirmer
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA, USA
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA, USA
| | - Ramin Zand
- Department of Neurology, Pennsylvania State University, 30 Hope Drive, PO Box 859, Hershey, PA 17033-0859, USA
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA, USA
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Péčová M, Benko J, Péč MJ, Bolek T, Hurtová T, Sokol J, Staško J, Samoš M, Mokáň M. Unilateral upper and lower limb ischemia mimics stroke: a case report. J Med Case Rep 2024; 18:66. [PMID: 38308343 PMCID: PMC10837969 DOI: 10.1186/s13256-023-04240-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 11/01/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Although stroke and acute limb ischemia seem easily distinguishable by anamnesis and physical examination, symptoms may overlap and sometimes mislead the examiner. Such a situation can arise in the occurrence of unilateral neurological symptoms affecting the upper and lower limbs at the same time. As timely diagnosis and a correct therapeutic intervention are crucial to prevent irreversible damage in both diseases, knowledge of the possibility of one disease mimicking the other is essential. We present a unique case of acute unilateral upper and lower limb ischemia mimicking an acute stroke. CASE PRESENTATION A 69-year-old Caucasian patient with known atherosclerotic risk factors was admitted to the emergency department with a suspected stroke with unilateral paresthesia. After a comprehensive examination of the patient with the need for repeated reevaluation and a negative brain computed tomography scan, acute left-sided upper and lower limb ischemia was eventually diagnosed. The patient underwent surgical revascularization of the upper and lower limbs with a satisfactory result and was discharged from the hospital after a few days. CONCLUSION It is of utmost importance to always stay alert for stroke mimics, as overlooking can lead to severe complications and delay adequate therapy. Our case shows that persistent diagnostic effort leads to successful treatment of the patient even on rare occasions, as is the acute unilateral upper and lower limb ischemia.
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Affiliation(s)
- Monika Péčová
- Oncology Centre, Teaching Hospital Martin, Kollárova 2, 036 01, Martin, Slovakia
- Department of Hematology and Transfusion Medicine, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
| | - Jakub Benko
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia.
- Department of Cardiology, Teaching Hospital Nitra, 950 01, Nitra, Slovakia.
| | - Martin Jozef Péč
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia.
| | - Tomáš Bolek
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
| | - Tatiana Hurtová
- Department of Infectology and Travel Medicine and Department of Dermatovenerology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
| | - Juraj Sokol
- Department of Hematology and Transfusion Medicine, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
| | - Ján Staško
- Department of Hematology and Transfusion Medicine, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
| | - Matej Samoš
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
- Division of Acute and Interventional Cardiology, Department of Cardiology and Angiology II., Mid-Slovakian Institute of Heart and Vessel Diseases (SÚSCCH, a.s.), 974 01, Banská Bystrica, Slovakia
| | - Marián Mokáň
- Department of Internal Medicine I., Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollárova 2, 036 01, Martin, Slovakia
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Jacobsen E, Logallo N, Kvistad CE, Thomassen L, Idicula T. Characteristics and predictors of stroke mimics in young patients in the norwegian tenecteplase stroke trial (NOR-TEST). BMC Neurol 2023; 23:406. [PMID: 37968581 PMCID: PMC10647039 DOI: 10.1186/s12883-023-03425-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 10/05/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Several studies have shown that stroke mimics occur more often among young patients. Our aims were to identify the common mimics in young patients under the age of 60 years who received thrombolysis, to analyze the risk of hemorrhage after treatment with thrombolysis, and to identify risk factors and clinical parameters that might identify mimics in this group. METHODS Norwegian Tenecteplase Stroke Trial was a phase-3 trial investigating safety and efficacy of tenecteplase vs. alteplase in patients with acute ischemic stroke. Patients diagnosed with either acute cerebral ischemia or transient ischemic attack were categorized as stroke group, and patients with any diagnosis other than ischemic stroke or transient ischemic attack as mimics group. Patients were grouped post-hoc into young (< 60 years) and old (≥ 60 years). Logistic regression analyses were performed with mimics vs. stroke as dependent variable to identify predictors of mimics. RESULTS Of the 1091 patients included in the trial, 211 patients (19.3%) were under the age of 60 years. Out of the 1091 patients, 434 (39.8%) were female, median age 77 years (18-99 years), and median NIHSS was 4. Sixty-nine patients (32.7%) out of the 211 patients under the age of 60 were diagnosed as mimic. Mimics were significantly more frequent among the young (OR = 3.3, 32.7% vs. 12.8%, p = < 0.001). The most frequent mimics diagnoses among patients under 60 years of age were migraine (11.8%), no definite diagnosis (11.4%) and peripheral vertigo (3.3%). Mimics were independently associated with age < 50 years (OR = 4.97, p = < 0.001), not currently working/studying (OR = 3.38, p = 0.002) and not having aphasia on admission (OR = 2.95, p = 0.025). None of the mimics under the age of 60 years had symptomatic or asymptomatic intracerebral hemorrhage as a complication to thrombolysis. CONCLUSION We found significantly more mimics in the young, of which migraine was the most predominant diagnosis. Thrombolysis with alteplase or tenecteplase did not cause ICH in any mimics under 60 years.
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Affiliation(s)
- Eskil Jacobsen
- Norwegian University of Science and Technology, Trondheim (NTNU), Trondheim, 7034, Norway.
| | - Nicola Logallo
- Department of Neurology, Centre for Neurovascular Diseases, Haukeland University Hospital, Bergen, 5021, Norway
| | - Christopher Elnan Kvistad
- Department of Neurology, Centre for Neurovascular Diseases, Haukeland University Hospital, Bergen, 5021, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Thomassen
- Department of Neurology, Centre for Neurovascular Diseases, Haukeland University Hospital, Bergen, 5021, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Titto Idicula
- Norwegian University of Science and Technology (NTNU), Trondheim, 7034, Norway
- Department of Neurology, St Olav University Hospital, Trondheim, Norway
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Nair R, Khan K, Stang JM, Halabi ML, Youngson E, Alrohimi A, Shuaib A. Thrombolysis in Stroke Mimics: Comprehensive Stroke Centers vs Telestroke Sites. Can J Neurol Sci 2023; 50:838-844. [PMID: 36453234 DOI: 10.1017/cjn.2022.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Hyperacute treatment of acute stroke may lead to thrombolysis in stroke mimics (SM). Our aim was to determine the frequency of thrombolysis in SM in primary stroke centers (PSC) dependent on telestroke versus comprehensive stroke centers (CSC). METHOD Retrospective review of prospectively collected data from the Quality improvement and Clinical Research (QuICR) registry, the Discharge Abstract Database (DAD), and The National Ambulatory Care Reporting System (NACRS) of consecutive patients treated with intravenous thrombolysis for acute ischemic stroke in Alberta (Canada) from April 2016 to March 2021. RESULT A total of 2471 patients who received thrombolysis were included. Linking the QuICR registry to DAD 169 (6.83%) patients were identified as SM; however, on our review of the records, only 112 (4.53%) were actual SM. SMs were younger with a mean age of 61.66 (±16.15) vs 71.08 (±14.55) in stroke. National Institute of Health Stroke Scale was higher in stroke with a median (IQR) of 10 (5-17) vs 7 (5-10) in SM. Only one patient (0.89 %) in SM groups had a small parenchymal hemorrhage versus 155 (6.57%) stroke patients had a parenchymal hemorrhage. There was no death among patients of thrombolysed SM during hospitalization versus 276 (11.69%) in stroke. There was no significant difference in the rate of SM among thrombolysed patients between PSC 27 (5.36%) versus CSC 85 (4.3%) (P = 0.312). The most responsible diagnosis of SM was migraine/migraine equivalent, functional disorder, seizure, and delirium. CONCLUSION The diagnosis of SM may not always be correct when the information is extracted from databases. The rate of thrombolysis in SM via telestroke is similar to treatment in person at CSC.
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Affiliation(s)
- Radhika Nair
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Khurshid Khan
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | | | | | | | - Anas Alrohimi
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
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Kolahchi Z, Rahimian N, Momtazmanesh S, Hamidianjahromi A, Shahjouei S, Mowla A. Direct Mechanical Thrombectomy Versus Prior Bridging Intravenous Thrombolysis in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. LIFE (BASEL, SWITZERLAND) 2023; 13:life13010185. [PMID: 36676135 PMCID: PMC9863165 DOI: 10.3390/life13010185] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/15/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND The current guideline recommends using an intravenous tissue-type plasminogen activator (IV tPA) prior to mechanical thrombectomy (MT) in eligible acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO). Some recent studies found no significant differences in the long-term functional outcomes between bridging therapy (BT, i.e., IV tPA prior to MT) and direct MT (dMT). METHODS We conducted a systematic review and meta-analysis to compare the safety and functional outcomes between BT and dMT in AIS patients with ELVO who were eligible for IV tPA administration. Based on the ELVO location, patients were categorized as the anterior group (occlusion of the anterior circulation), or the combined group (occlusion of the anterior and/or posterior circulation). A subgroup analysis was performed based on the study type, i.e., RCT and non-RCT. RESULTS Thirteen studies (3985 patients) matched the eligibility criteria. Comparing the BT and dMT groups, no significant differences in terms of mortality and good functional outcome were observed at 90 days. Symptomatic intracranial hemorrhagic (sICH) events were more frequent in BT patients in the combined group (OR = 0.73, p = 0.02); this result remained significant only in the non-RCT subgroup (OR = 0.67, p = 0.03). The RCT subgroup had a significantly higher rate of successful revascularization in BT patients (OR = 0.73, p = 0.02). CONCLUSIONS Our meta-analysis uncovered no significant differences in functional outcome and mortality rate at 90 days between dMT and BT in patients with AIS who had ELVO. Although BT performed better in terms of successful recanalization rate, there is a risk of increased sICH rate in this group.
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Affiliation(s)
- Zahra Kolahchi
- School of Medicine, Tehran University of Medical Sciences, Tehran 1417613151, Iran
| | - Nasrin Rahimian
- Department of Neurology, Creighton University Medical Center, Omaha, NE 68124, USA
| | - Sara Momtazmanesh
- School of Medicine, Tehran University of Medical Sciences, Tehran 1417613151, Iran
| | - Anahid Hamidianjahromi
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Shima Shahjouei
- Department of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Correspondence: ; Tel.: +323-409-7422; Fax: +323-226-7833
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Khalili N, Wang R, Garg T, Ahmed A, Hoseinyazdi M, Sair HI, Luna LP, Intrapiromkul J, Deng F, Yedavalli V. Clinical application of brain perfusion imaging in detecting stroke mimics: A review. J Neuroimaging 2023; 33:44-57. [PMID: 36207276 DOI: 10.1111/jon.13061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 02/01/2023] Open
Abstract
Stroke mimics constitute a significant proportion of patients with suspected acute ischemic stroke. These conditions may resemble acute ischemic stroke and demonstrate abnormalities on perfusion imaging sequences. The most common stroke mimics include seizure/epilepsy, migraine with aura, brain tumors, functional disorders, infectious encephalopathies, Wernicke's encephalopathy, and metabolic abnormalities. Brain perfusion imaging techniques, particularly computed tomography perfusion and magnetic resonance perfusion, are being widely used in routine clinical practice for treatment selection in patients presenting with large vessel occlusion. At the same time, the utilization of these imaging modalities enables the opportunity to better diagnose patients with stroke mimics in a time-sensitive setting, leading to appropriate management, decision-making, and resource allocation. In this review, we describe patterns of perfusion abnormalities that could discriminate patients with stroke mimics from those with acute ischemic stroke and provide specific case examples to illustrate these perfusion abnormalities. In addition, we discuss the challenges associated with interpretation of perfusion images in stroke-related pathologies. In general, perfusion imaging can provide additional information in some cases-when used in combination with conventional magnetic resonance imaging and computed tomography-and might help in detecting stroke mimics among patients who present with acute onset focal neurological symptoms.
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Affiliation(s)
- Neda Khalili
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Richard Wang
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Tushar Garg
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Amara Ahmed
- Department of Radiology, Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Meisam Hoseinyazdi
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Haris I Sair
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Licia P Luna
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jarunee Intrapiromkul
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Francis Deng
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Bahrami Z, Salimi M, Ostovan VR. Severe Hyperkalemia Masquerading as Acute Ischemic Stroke: A Case Report. IRANIAN JOURNAL OF MEDICAL SCIENCES 2022; 47:608-611. [PMID: 36380974 PMCID: PMC9652496 DOI: 10.30476/ijms.2021.91382.2253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/18/2021] [Accepted: 08/28/2021] [Indexed: 11/25/2022]
Abstract
Severe hyperkalemia usually presents as cardiac or neurologic manifestations. We report a case of a 63-year-old Caucasian woman, who was admitted to Namazi Hospital, affiliated with Shiraz University of Medical Sciences (Shiraz, Iran) in August 2019. The patient suffered from left-sided weakness and slurred speech for one hour prior to admission. Initially, the patient was treated for acute ischemic stroke, and an intravenous recombinant tissue plasminogen activator (IV-rTPA) was prescribed. However, further investigations showed severe hyperkalemia. Hemiparesis and slurred speech improved significantly with appropriate management of hyperkalemia. To the best of our knowledge, this is the first case of hyperkalemia masquerading as acute ischemic stroke without evidence of concomitant central nervous system malignancies, large vessel atherosclerosis, or recreational drug abuse. Stroke mimics due to hyperkalemia should be considered in any patient with simultaneous sudden onset of focal neurologic deficits and tall peaked T waves, particularly in the context of renal failure and a history of potassium-sparing drug use.
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Affiliation(s)
- Zahra Bahrami
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Marzieh Salimi
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vahid Reza Ostovan
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Wang Y, Jing J, Pan Y, Wang M, Meng X, Wang Y. Distribution and prognosis of acute ischaemic stroke with negative diffusion-weighted imaging. Stroke Vasc Neurol 2022; 7:493-499. [PMID: 35697388 PMCID: PMC9811538 DOI: 10.1136/svn-2021-001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 06/03/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND AND PURPOSE To examine the distribution and prognosis among patients with diffusion-weighted imaging (DWI)-negative acute ischaemic stroke (AIS) and explore the differences between mild (National Institute of Health Stroke Scale (NIHSS) score ≤5) and major (NIHSS score >5) ischaemic stroke in DWI-negative patients. METHODS Patients with AIS with baseline DWI from the Third China National Stroke Registry (CNSR-III), based on a prospective, observational, multicentre cohort study, between August 2015 and March 2018, were included. Patients were classified into negative and positive DWI groups depending on the existence of acute lesions on DWI. RESULTS Among 12 026 patients who had an ischaemic stroke, 932 (7.7%) had negative DWI. As the NIHSS score increased, the proportion of patients with DWI-negative AIS gradually decreased. Negative DWI was associated with a decreased risk of stroke recurrence (HR 0.63, 95% CI 0.49 to 0.82), combined vascular events (HR 0.72, 95% CI 0.56 to 0.92), mortality (HR 0.60, 95% CI 0.36 to 0.995) and poor functional outcomes (OR 0.57, 95% CI 0.43 to 0.76) within 1 year in all patients. Similar associations were observed in patients with mild AIS (p<0.05 for all) but not in patients with major AIS, excluding poor functional outcomes (OR 0.47, 95% CI 0.28 to 0.81). CONCLUSIONS The proportion of patients with DWI-negative AIS gradually decreased as the NIHSS score increased, and negative DWI was mainly observed in patients with mild AIS. Negative DWI was associated with a better prognosis for all patients with AIS. However, these associations were significant for mild AIS but not for those with major AIS.
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Affiliation(s)
- Yu Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Mengxing Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese academy of Medical Sciences, Beijing, China,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China,Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Beijing, China
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Walter S, Audebert HJ, Katsanos AH, Larsen K, Sacco S, Steiner T, Turc G, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management. Eur Stroke J 2022; 7:XXVII-LIX. [PMID: 35300251 PMCID: PMC8921783 DOI: 10.1177/23969873221079413] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/23/2022] [Indexed: 08/03/2023] Open
Abstract
The safety and efficacy of mobile stroke units (MSUs) in prehospital stroke management has recently been investigated in different clinical studies. MSUs are ambulances equipped with a CT scanner, point-of-care lab, telemedicine and are staffed with a stroke specialised medical team. This European Stroke Organisation (ESO) guideline provides an up-to-date evidence-based recommendation to assist decision-makers in their choice on using MSUs for prehospital management of suspected stroke, which includes patients with acute ischaemic stroke (AIS), intracranial haemorrhage (ICH) and stroke mimics. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and aggregated data meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements are provided where sufficient evidence was not available to provide recommendations based on the GRADE approach. We found moderate evidence for suggesting MSU management for patients with suspected stroke. The patient group diagnosed with AIS shows an improvement of functional outcomes at 90 days, reduced onset to treatment times and increased proportion receiving IVT within 60 min from onset. MSU management might be beneficial for patients with ICH as MSU management was associated with a higher proportion of ICH patients being primarily transported to tertiary care stroke centres. No safety concerns (all-cause mortality, proportion of stroke mimics treated with IVT, symptomatic intracranial bleeding and major extracranial bleeding) could be identified for all patients managed with a MSU compared to conventional care. We suggest MSU management to improve prehospital management of suspected stroke patients.
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Affiliation(s)
- Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université de Paris, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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Kim T, Jeong HY, Suh GJ. Clinical Differences Between Stroke and Stroke Mimics in Code Stroke Patients. J Korean Med Sci 2022; 37:e54. [PMID: 35191231 PMCID: PMC8860772 DOI: 10.3346/jkms.2022.37.e54] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/02/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The code stroke system is designed to identify stroke patients who may benefit from reperfusion therapy. It is essential for emergency physicians to rapidly distinguish true strokes from stroke mimics to activate code stroke. This study aimed to investigate the clinical and neurological characteristics that can be used to differentiate between stroke and stroke mimics in the emergency department (ED). METHODS We conducted a retrospective observational study of code stroke patients in the ED from January to December 2019. The baseline characteristics and the clinical and neurological features of stroke mimics were compared with those of strokes. RESULTS A total of 409 code stroke patients presented to the ED, and 125 (31%) were diagnosed with stroke mimics. The common stroke mimics were seizures (21.7%), drug toxicity (12.0%), metabolic disorders (11.2%), brain tumors (8.8%), and peripheral vertigo (7.2%). The independent predictors of stroke mimics were psychiatric disorders, dizziness, altered mental status, and seizure-like movements, while current smoking, elevated systolic blood pressure, atrial fibrillation on the initial electrocardiogram, hemiparesis as a symptom, and facial palsy as a sign suggested a stroke. In addition, the likelihood of a stroke in code stroke patients tended to increase as the number of accompanying deficits increased from the following set of seven focal neurological deficits: hemiparesis (or upper limb monoparesis), unilateral limb sensory change, facial palsy, dysarthria, aphasia (or neglect), visual field defect, and oculomotor disorder (P < 0.001). CONCLUSION Some clinical and neurological characteristics have been identified to help differentiate stroke mimics from true stroke. In particular, the likelihood of stroke tended to increase as the number of accompanying focal neurological deficits increased.
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Affiliation(s)
- Taekwon Kim
- Department of Emergency Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Han-Yeong Jeong
- Department of Neurology, Emergency Medical Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea.
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12
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Prodi E, Danieli L, Manno C, Pagnamenta A, Pravatà E, Roccatagliata L, Städler C, Cereda CW, Cianfoni A. Stroke Mimics in the Acute Setting: Role of Multimodal CT Protocol. AJNR Am J Neuroradiol 2022; 43:216-222. [PMID: 34969667 PMCID: PMC8985681 DOI: 10.3174/ajnr.a7379] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke can be mimicked by nonischemic conditions. Due to emphasis on the rapid treatment of acute ischemic stroke, it is crucial to identify these conditions to avoid unnecessary therapies and potential complications. We investigated the performance of the multimodal CT protocol (unenhanced brain CT, CTA, and CTP) to discriminate stroke mimics from acute ischemic stroke. MATERIALS AND METHODS We retrospectively selected multimodal CT studies performed for clinical suspicion of acute ischemic stroke in our center in a 24-month period, including patients with at least 1 follow-up imaging study (brain CT or MR imaging). Hemorrhagic strokes were excluded. We measured the performance of multimodal CT, comparing the original diagnostic results with the final clinical diagnosis at discharge. RESULTS Among 401 patients, a stroke mimic condition was diagnosed in 89 (22%), including seizures (34.8%), migraine with aura attack (12.4%), conversion disorder (12.4%), infection (7.9%), brain tumor (7.9%), acute metabolic condition (6.7%), peripheral vertigo (5.6%), syncope (5.6%), transient global amnesia (3.4%), subdural hematoma (1.1%), cervical epidural hematoma (1.1%), and dural AVF (1.1%). Multimodal CT sensitivity, specificity, and accuracy were 24.7%, 99.7%, and 83%. Multimodal CT revealed peri-ictal changes in 13/31 seizures and diagnosed 7/7 brain tumors, 1/1 dural AVF, and 1/1 subdural hematoma. CT perfusion played a pivotal diagnostic role. CONCLUSIONS Multimodal CT demonstrated low sensitivity but high specificity in the diagnosis of stroke mimics in the acute setting. The high specificity of multimodal CT allows ruling out stroke and thereby avoiding unnecessary revascularization treatment in patients with diagnosis of a stroke mimic.
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Affiliation(s)
- E Prodi
- From the Departments of Neuroradiology (E.Prodi, L.D., E.Pravatà, A.C.)
| | - L Danieli
- From the Departments of Neuroradiology (E.Prodi, L.D., E.Pravatà, A.C.)
| | - C Manno
- Neurology (C.M., C.S., C.W.C.), Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
| | - A Pagnamenta
- Unit of Clinical Epidemiology (A.P.), Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Department of Intensive Care Medicine (A.P.), Ente Ospedaliero Cantonale, Mendrisio, Switzerland
- Division of Pneumology (A.P.), University Hospital of Geneva, Geneva, Switzerland
| | - E Pravatà
- From the Departments of Neuroradiology (E.Prodi, L.D., E.Pravatà, A.C.)
- Faculty of Biomedical Sciences (E. Pravatà), Università della Svizzera Italiana, Lugano, Switzerland
| | - L Roccatagliata
- Department of Health Science (DISSAL) (L.R.), University of Genova, Genova, Italy
| | - C Städler
- Neurology (C.M., C.S., C.W.C.), Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
| | - C W Cereda
- Neurology (C.M., C.S., C.W.C.), Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
| | - A Cianfoni
- Department of Neuroradiology (A.C.), Inselspital Bern, University of Bern, Bern, Switzerland
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13
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Lee VH, Howell R, Yadav R, Heaton S, Wiles KL, Lakhani S. Thrombolysis of stroke mimics via telestroke. Stroke Vasc Neurol 2022; 7:267-270. [PMID: 35105730 PMCID: PMC9240458 DOI: 10.1136/svn-2020-000776] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/22/2021] [Indexed: 11/20/2022] Open
Abstract
Background The rate of intravenous tissue plasminogen activator (IVtPA) administered to stroke mimics (SM) occurs in 24%–44% of telestroke series. Methods We reviewed 270 suspected acute ischaemic stroke (AIS) patients who were evaluated by telestroke and received IVtPA from 1 July 2016 to 30 September 2017 at our academic comprehensive stroke centre. Results Among 270 AIS patients who received IVtPA via telestroke, 64 (23.7%) were diagnosed with SM. Compared with patients who had a stroke, the SM group was younger (mean age 56.4 vs 68.2, p<0.0001), more likely to be female (60.9% vs 45.6%, p=0.0324) and had longer door-to-needle times (85.3 vs 69.9, p=0.0008). The most common SM diagnoses were migraine 26 (40.6%), conversion disorder 12 (18.8%), encephalopathy 7 (10.9%) and unmasking (9.4%). Among the SM, migraine and conversion disorder were younger compared with the other subgroups (p<0.001). Functional exam elements were noted more frequently in conversion disorder (66.7%) and migraine (34.6%), but rare in other diagnoses (p=0.006). Among the SM, 23 (35.9%) had a history of a prior similar episodes, and 15 (23.4%) had a history of more than 5 spells. Conclusions In our telestroke programme, 23.7% of those administered thrombolysis had a final diagnosis of SM.
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Affiliation(s)
- Vivien H Lee
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ravyn Howell
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Randheer Yadav
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sharon Heaton
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Karen L Wiles
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sushil Lakhani
- Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Abstract
PURPOSE OF REVIEW The aim of this study was to summarize available evidence regarding the safety and efficacy of intravenous thrombolysis (IVT) using recombinant tissue-plasminogen activator (rt-PA) in acute ischemic stroke (AIS) patients with specific comorbidities and potential contraindications to systemic reperfusion therapy. Recent advances in IVT implementation in wake-up stroke and in extended time window using advanced neuroimaging will also be highlighted. RECENT FINDINGS Despite theoretical concerns of a higher bleeding risk with IVT, there are no data showing increased risk of symptomatic intracerebral haemorrhage (sICH) in patients with stroke mimics, including seizures, increasing age and dual antiplatelet pretreatment. In addition, recent randomized evidence allows us to expand the time window of IVT for AIS using advanced neuroimaging both in wake-up stroke patients and in patients presenting within 4.5-9 h from symptom onset fulfilling certain neuroimaging criteria (based on DWI/FLAIR mismatch or perfusion mismatch). SUMMARY IVT is a highly effective systemic reperfusion therapy that counts 25 years of everyday clinical experience but still presents several challenges in its application. Appropriate patient selection and adherence to rt-PA protocol is paramount in terms of safety. The effort to simplify the indications, expand the therapeutic time window and eliminate specific initial contraindications is continuously evolving.
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Affiliation(s)
- Klearchos Psychogios
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
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15
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Davies E, Elnagi F, Smith T. CT perfusion: stroke, seizure or both? BMJ Case Rep 2021; 14:14/12/e245723. [PMID: 34969793 PMCID: PMC8719119 DOI: 10.1136/bcr-2021-245723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
An 88-year-old male with a history of hypertension, ischaemic heart disease and Bell’s palsy presented with symptoms and signs of an acute ischaemic stroke. National Institutes of Health Stroke Scale (NIHSS) was 19 at presentation, indicative of potential large vessel occlusion. The initial CT scan revealed evidence of small vessel disease and arterial calcification. As there were no contraindications, he received thrombolytic treatment. CT angiography and CT perfusion imaging were performed in preparation for possible thrombectomy. There was no evidence of a large vessel thrombus, and changes on CT perfusion were suggestive of seizure activity, with relative hyperperfusion on the cerebral hemisphere of interest. Post thrombolysis, his NIHSS was 5. An MR scan revealed evidence of bilateral thalamic infarcts. After a period of rehabilitation, he was discharged home and independently mobile but with cognitive impairment. Acute stroke care increasingly uses multimodal imaging to confirm the clinical diagnosis and help optimise initial emergency management. Such imaging is useful in determining whether the presentation is a vascular event or stroke mimic. Moreover, seizures complicate and mimic acute strokes, which can lead to therapeutic uncertainty. This case highlights the increasingly sophisticated investigation of patients presenting with suspected acute stroke, with the attendant need for accurate interpretation by experienced clinicians.
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Affiliation(s)
- Elizebath Davies
- St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Fathalla Elnagi
- Stroke, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Thomas Smith
- St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
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16
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Measuring the effect of thrombosis, thrombus maturation and thrombolysis on clot mechanical properties in an in-vitro model. J Biomech 2021; 129:110731. [PMID: 34601216 DOI: 10.1016/j.jbiomech.2021.110731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/23/2021] [Accepted: 07/25/2021] [Indexed: 01/05/2023]
Abstract
Changes in acute ischemic stroke thrombi structure and composition may result in significant differences in treatment responsiveness. Ischemic stroke patients are often treated with a thrombolytic agent to dissolve thrombi, however these patients may subsequently undergo mechanical thrombectomy to remove the occlusive clot. We set out to determine if rt-PA thrombolysis treatment of blood clots changes their mechanical properties, which in turn may impact mechanical thrombectomy. Using a design-of-experiment approach, ovine clot analogues were prepared with varying composition and further exposed to different levels of compaction force to simulate the effect of arterial blood pressure. Finally, clots were treated with three r-tPA doses for different durations. Clot mass and mechanical behaviour was analysed to assess changes due to (i) Platelet driven contraction (ii) Compaction force and (iii) Thrombolysis. Clots that were exposed to r-tPA for longer duration showed significant reduction in clot mass (p < 0.001). Exposure time to r-tPA (p < 0.001) was shown to be an independent predictor of lower clot stiffness. A decrease in energy dissipation ratio during mechanical compression was associated with longer exposure time in r-tPA (p = 0.001) and a higher platelet concentration ratio (p = 0.018). The dose of r-tPA was not a significant factor in reducing clot mass or changing mechanical properties of the clots. Fibrinolysis reduces clot stiffness which may explain increased distal clot migration observed in patients treated with r-tPA and should be considered as a potential clot modification factor before mechanical thrombectomy.
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17
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H. Buck B, Akhtar N, Alrohimi A, Khan K, Shuaib A. Stroke mimics: incidence, aetiology, clinical features and treatment. Ann Med 2021; 53:420-436. [PMID: 33678099 PMCID: PMC7939567 DOI: 10.1080/07853890.2021.1890205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022] Open
Abstract
Mimics account for almost half of hospital admissions for suspected stroke. Stroke mimics may present as a functional (conversion) disorder or may be part of the symptomatology of a neurological or medical disorder. While many underlying conditions can be recognized rapidly by careful assessment, a significant proportion of patients unfortunately still receive thrombolysis and admission to a high-intensity stroke unit with inherent risks and unnecessary costs. Accurate diagnosis is important as recurrent presentations may be common in many disorders. A non-contrast CT is not sufficient to make a diagnosis of acute stroke as the test may be normal very early following an acute stroke. Multi-modal CT or magnetic resonance imaging (MRI) may be helpful to confirm an acute ischaemic stroke and are necessary if stroke mimics are suspected. Treatment in neurological and medical mimics results in prompt resolution of the symptoms. Treatment of functional disorders can be challenging and is often incomplete and requires early psychiatric intervention.
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Affiliation(s)
- Brian H. Buck
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
| | - Naveed Akhtar
- Neurological Institute, Hamad Medical Corporation, Doha, Qatar
| | - Anas Alrohimi
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
- Department of Medicine (Neurology), King Saud University, Riyadh, Saudi Arabia
| | - Khurshid Khan
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
| | - Ashfaq Shuaib
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada
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Barra M, Faiz KW, Dahl FA, Næss H. Stroke Mimics on the Stroke Unit - Temporal trends 2008-2017 at a large Norwegian university hospital. Acta Neurol Scand 2021; 144:695-705. [PMID: 34498731 DOI: 10.1111/ane.13527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/11/2021] [Accepted: 08/19/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective was to quantify temporal trends in stroke mimics (SM) admissions relative to cerebrovascular accidents (CVA), incidence of hospitalized SMs and characterize the SM case-mix at a general hospital's stroke unit (SU). MATERIALS & METHODS All SU admissions (n = 11240) of patients aged 15 or older to Haukeland University Hospital between 2008-2017 were prospectively included and categorized as CVA or SM. Logistic regression was used to estimate time trends in the proportion of SMs among the admissions. Poisson regression was used to estimate time trends in age- and sex-dependent SM incidence. RESULTS SMs were on average younger thaan CVA patients (68.3 vs. 71.4 years) and had a higher proportion of females (53.6% vs. 44.5%). The total proportion of SM admissions was 51.0%. There was an increasing time trend in the proportion of SM admissions, odds ratio 1.150 per year (p < 0.001), but this trend appears flattening, represented by a significant quadratic time-term, odds ratio 1.009 (p < 0.001). A higher SM proportion was also associated with the time period of a Mass Media Intervention (FAST campaign) in 2014. There was also an increasing trend in SM incidence, that remains after adjusting for age, sex, and population; also, for incidence the trend appears to be flattening. CONCLUSIONS SMs account for approximately half of the SU admissions, and the proportion has been increasing. A FAST campaign appears to have temporarily increased the SM proportion. The age- and sex-dependent incidence of SM has been increasing but appears to flatten out.
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Affiliation(s)
- Mathias Barra
- The Health Services Research Unit (HØKH) Akershus University Hospital HF Lørenskog Norway
- Institute for Global Health BCEPSUniversity of Bergen Bergen Norway
| | - Kashif Waqar Faiz
- The Health Services Research Unit (HØKH) Akershus University Hospital HF Lørenskog Norway
- Department of Neurology Akershus University Hospital HF Lørenskog Norway
| | - Fredrik Andreas Dahl
- The Health Services Research Unit (HØKH) Akershus University Hospital HF Lørenskog Norway
| | - Halvor Næss
- Department of Neurology Haukeland University Hospital HF Bergen Norway
- Centre for age‐related medicine Stavanger University Hospital Stavanger Norway
- Institute of clinical medicine University of Bergen Bergen Norway
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Lakatos LB, Christ M, Müller M, Bolognese M. „Stroke mimics“ – Differenzialdiagnose des Schlaganfalls in der Notfallmedizin. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00877-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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Pohl M, Hesszenberger D, Kapus K, Meszaros J, Feher A, Varadi I, Pusch G, Fejes E, Tibold A, Feher G. Ischemic stroke mimics: A comprehensive review. J Clin Neurosci 2021; 93:174-182. [PMID: 34656244 DOI: 10.1016/j.jocn.2021.09.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/01/2021] [Accepted: 09/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Ischemic stroke is the leading cause of disability and one of the leading causes of death. Ischemic stroke mimics (SMs) can account for a noteble number of diagnosed acute strokes and even can be thrombolyzed. METHODS The aim of our comprehensive review was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of SMs in stroke/thrombolysis situations. RESULTS Overall, 61 studies were selected with 62.664 participants. Ischemic stroke mimic rate was 24.8% (15044/60703). Most common types included peripheral vestibular dysfunction in 23.2%, toxic/metabolic in 13.2%, seizure in 13%, functional disorder in 9.7% and migraine in 7.76%. Ischemic stroke mimic have less vascular risk factors, younger age, female predominance, lower (nearly normal) blood pressure, no or less severe symptoms compared to ischemic stroke patients (p < 0.05 in all cases). 61.7% of ischemic stroke patients were thrombolysed vs. 26.3% among SMs (p < 0.001). (p < 0.001). Overall intracranial hemorrhage was reported in 9.4% of stroke vs. 0.7% in SM patients (p < 0.001). Death occurred in 11.3% of stroke vs 1.9% of SM patients (p < 0.001). Excellent outcome was (mRS 0-1) was reported in 41.8% ischemic stroke patients vs. 68.9% SMs (p < 0.001). Apart from HINTS manouvre or Hoover sign there is no specific method in the identification of mimics. MRI DWI or perfusion imaging have a role in the setup of differential diagnosis, but merit further investigation. CONCLUSION Our article is among the first complex reviews focusing on ischemic stroke mimics. Although it underscores the safety of thrombolysis in this situation, but also draws attention to the need of patient evaluation by physicians experienced in the diagnosis of both ischemic stroke and SMs, especially in vertigo, headache, seizure and conversional disorders.
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Affiliation(s)
- Marietta Pohl
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | | | - Krisztian Kapus
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Janos Meszaros
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | | | - Imre Varadi
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | | | | | - Antal Tibold
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Gergely Feher
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary; Neurology Outpatient Clinic, EÜ-MED KFT, Komló, Hungary.
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Mikulik R, Bar M, Cernik D, Herzig R, Jura R, Jurak L, Neumann J, Sanak D, Ostry S, Sevcik P, Skoda O, Skoloudik D, Vaclavik D, Tomek A. Stroke 20 20: Implementation goals for intravenous thrombolysis. Eur Stroke J 2021; 6:151-159. [PMID: 34414290 DOI: 10.1177/23969873211007684] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/16/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction Knowledge of the implementation gap would facilitate the use of intravenous thrombolysis in stroke, which is still low in many countries. The study was conducted to identify national implementation targets for the utilisation and logistics of intravenous thrombolysis. Material and Method Multicomponent interventions by stakeholders in health care to optimise prehospital and hospital management with the goal of fast and accessible intravenous thrombolysis for every candidate. Implementation results were documented from prospectively collected cases in all 45 stroke centres nationally. The thrombolytic rate was calculated from the total number of all ischemic strokes in the population of the Czech Republic since 2004. Results Thrombolytic rates of 1.3 (95%CI 1.1 to 1.4), 5.4 (95%CI 5.1 to 5.7), 13.6 (95%CI 13.1 to 14.0), 23.3 (95%CI 22.8 to 23.9), and 23.5% (95%CI 23.0 to 24.1%) were achieved in 2005, 2009, 2014, 2017, and 2018, respectively. National median door-to-needle times were 60-70 minutes before 2012 and then decreased progressively every year to 25 minutes (IQR 17 to 36) in 2018. In 2018, 33% of both university and non-university hospitals achieved median door-to-needle time ≤20 minutes. In 2018, door-to-needle times ≤20, ≤45, and ≤60 minutes were achieved in 39, 85, and 93% of patients. Discussion Thrombolysis can be provided to ≥ 20% of all ischemic strokes nationwide and it is realistic to achieve median door-to-needle time 20 minutes. Conclusion Stroke 20-20 could serve as national implementation target for intravenous thrombolysis and country specific implementation policies should be applied to achieve such target.
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Affiliation(s)
- Robert Mikulik
- International Clinical Research Center and Department of Neurology, St. Anne's University Hospital Brno, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michal Bar
- Department of Neurology, University Faculty Hospital Ostrava and Faculty of Medicine, University Ostrava, Ostrava, Czech Republic
| | - David Cernik
- Department of Neurology, Masaryk Hospital Usti nad Labem - KZ a.s., Comprehensive Stroke Center, Usti nad Labem, Czech Republic
| | - Roman Herzig
- Comprehensive Stroke Center, University Hospital Hradec Kralove and Charles University Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Rene Jura
- Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Neurology, University Hospital Brno, Brno, Czech Republic
| | - Lubomir Jurak
- Neurocenter, Regional Hospital Liberec, Liberec, Czech Republic
| | - Jiri Neumann
- Department of Neurology, County Hospital Chomutov, Chomutov, Czech Republic
| | - Daniel Sanak
- Department of Neurology, Comprehensive Stroke Center, Palacký University Medical School and Hospital, Olomouc, Czech Republic
| | - Svatopluk Ostry
- Department of Neurology, Hospital Ceske Budejovice, a.s., Ceske Budejovice, Czech Republic.,Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University in Prague and Military University Hospital Prague, Prague, Czech Republic
| | - Petr Sevcik
- Department of Neurology, Charles University Faculty of Medicine in Pilsen, Pilsen, Czech Republic.,Department of Neurology, University Hospital Pilsen, Pilsen, Czech Republic
| | - Ondrej Skoda
- Department of Neurology, Hospital Jihlava, Jihlava, Czech Republic.,Department of Neurology, 3rd Medical School of Charles University and Vinohrady University Hospital, Prague, Czech Republic
| | - David Skoloudik
- Department of Nursing, Faculty of Health Science, Palacký University Olomouc, Olomouc, Czech Republic
| | - Daniel Vaclavik
- Department of Neurology and AGEL Research and Training Institute, Ostrava Vitkovice Hospital, Ostrava, Czech Republic
| | - Ales Tomek
- Department of Neurology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
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22
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Carlin R, Zhang N, Demaerschalk BM. Validation of the Telestroke Mimic Score in Mayo Clinic population. J Stroke Cerebrovasc Dis 2021; 30:106021. [PMID: 34388405 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/03/2021] [Accepted: 07/18/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Telestroke consultations enable hospital providers to administer intravenous (IV) alteplase to patients who would otherwise not receive it due to lack of an in-hospital stroke team. However, up to 30% of acute stroke patient evaluations are deemed to be stroke mimics. Mimics present a challenge with the limitations of a virtual neurological exam. The administration of IV alteplase in these patients is not without risk. With the cost and risk associated with IV alteplase, there are both ethical and practical incentives to avoid administering alteplase to a patient manifesting a stroke-mimic. Recently a retrospective analysis validated a TeleStroke Mimic Score (TM-Score) to help detect stroke mimics. We retrospectively applied this tool to Mayo Clinic Stroke Telemedicine for Arizona Rural Residents (STARR) telestroke database to provide external validation in an independent study population. MATERIALS AND METHODS We analyzed 339 patients in the STARR database for validation of the TM-Score, which was applied retrospectively to determine whether it predicted stroke-mimic, using data available during each patient's telestroke consult. We assessed the TM-Score's performance with a receiver-operating characteristic (ROC) curve. A scatter plot of the data was assembled to demonstrate the relationship between the TM-Score and the likelihood of having a stroke mimic, and was compared to the nomogram in the original TM-Score study. RESULTS When the TM-Score was applied to Mayo Clinic STARR validation cohort, the area under the ROC curve was 0.78, larger than that of the derivation cohort in the original study (0.75). Further analysis suggested that a TM-Score > 25 or < 10 provided a greater degree of confidence that the patient had presented with stroke or stroke mimic, respectively. In STARR cohort, additional variables were significantly different between stroke and stroke mimic populations, including a history of sleep apnea and diabetes. CONCLUSIONS We determined that the original TM-Score was valid when applied to Mayo Clinic STARR telestroke population.
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Affiliation(s)
- Rachel Carlin
- Department of Neurology, Mayo Clinic College of Medicine and Science, Phoenix, AZ, US.
| | - Nan Zhang
- Department of Biostatistics, Mayo Clinic College of Medicine and Science, Phoenix, AZ, US.
| | - Bart M Demaerschalk
- Department of Neurology, Center for Connected Care, Center for Digital Health, Rochester, MN, US; Mayo Clinic College of Medicine and Science, Phoenix, AZ, US.
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23
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Sidorov E, Iser C, Kapoor N, Ray B, Chainakul J, Xu C, Alexandrov AV, Gordon DL. Criteria for Emergency Brain MRI During Stroke-Alert. J Stroke Cerebrovasc Dis 2021; 30:105890. [PMID: 34107417 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/29/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES Intravenous (IV) tissue plasminogen activator (tPA) should be given to patients with acute ischemic stroke (AIS) and avoided in stroke mimics (SM). Select use of emergency brain magnetic resonance imaging (eMRI-brain) in stroke-alerts aids diagnosis, but accepted utilization criteria for eMRI-brain do not currently exist. We developed criteria for eMRI-brain and report the yield of eMRI-brain in stroke-alert patients. MATERIALS AND METHODS We developed three history-based criteria for performing eMRI-brain during stroke-alerts: (1) history of previous similar deficits, (2) change in consciousness at onset of symptoms, (3) symptom presentation consistent with migraine aura. We then performed a retrospective chart review of patients who presented as a stroke-alert over a 5-year period and determined how these criteria affected administration of IV tPA to AIS and SM patients. RESULTS Among 3,512 stroke-alerts, 230 (8.1%) patients met our criteria for eMRI-brain exams: 217 (92.6%) had SM and 17 (7.4%) had AIS. Our IV tPA decision-making analysis showed that based on eMRI-brain IV tPA was less frequently administered to SM patients (PCC-0.841, p=0.036) with less failures to administer IV tPA to patients with AIS (PCC -0.907, p-value=0.013, Pearson correlation coefficient). No patients became ineligible for IV tPA due to MRI-related time delays. CONCLUSIONS Our history based criteria for performing eMRI-brain during stroke-alerts show a high yield of stroke mimics. Selective eMRI-brain improves decision-making accuracy regarding IV tPA administration.
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Affiliation(s)
- Evgeny Sidorov
- Department of Neurology, University of Oklahoma Health Sciences Center, 920 S.L.Young Blvd #2040, Oklahoma City, OK 73104, USA; Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, 1100 N Lindsay Ave., Oklahoma City, OK 73104, USA.
| | - Courtney Iser
- Department of Neurology, University of Oklahoma Health Sciences Center, 920 S.L.Young Blvd #2040, Oklahoma City, OK 73104, USA
| | - Nidhi Kapoor
- University of Arkansas, Department of Neurology 4301 W. Markham St., Slot 500 Little Rock, AR 72205, USA
| | - Bappaditya Ray
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX 75390, USA
| | - Juliane Chainakul
- Department of Neurology, University of Oklahoma Health Sciences Center, 920 S.L.Young Blvd #2040, Oklahoma City, OK 73104, USA
| | - Chao Xu
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, 801 N.E. 13th Street, Oklahoma City, OK 73104 USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, 847 Monroe Ave Suite M226, Memphis, TN 38163
| | - David Lee Gordon
- Department of Neurology, University of Oklahoma Health Sciences Center, 920 S.L.Young Blvd #2040, Oklahoma City, OK 73104, USA; Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, 1100 N Lindsay Ave., Oklahoma City, OK 73104, USA
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24
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Finkelstein SA, Cortel‐LeBlanc MA, Cortel‐LeBlanc A, Stone J. Functional neurological disorder in the emergency department. Acad Emerg Med 2021; 28:685-696. [PMID: 33866653 DOI: 10.1111/acem.14263] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 12/27/2022]
Abstract
We provide a narrative review of functional neurological disorder (FND, or conversion disorder) for the emergency department (ED). Diagnosis of FND has shifted from a "rule-out" disorder to one now based on the recognition of positive clinical signs, allowing the ED physician to make a suspected or likely diagnosis of FND. PubMed, Google Scholar, academic books, and a hand search through review article references were used to conduct a literature review. We review clinical features and diagnostic pitfalls for the most common functional neurologic presentations to the ED, including functional limb weakness, functional (nonepileptic) seizures, and functional movement disorders. We provide practical advice for discussing FND as a possible diagnosis and suggestions for initial steps in workup and management plans.
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Affiliation(s)
| | - Miguel A. Cortel‐LeBlanc
- Faculty of Medicine University of Ottawa Ottawa Ontario Canada
- The Ottawa Hospital Ottawa Ontario Canada
- Queensway Carleton Hospital Ottawa Ontario Canada
| | - Achelle Cortel‐LeBlanc
- Faculty of Medicine University of Ottawa Ottawa Ontario Canada
- Queensway Carleton Hospital Ottawa Ontario Canada
| | - Jon Stone
- Centre for Clinical Brain Sciences University of Edinburgh Edinburgh UK
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25
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Larsen K, Jaeger HS, Tveit LH, Hov MR, Thorsen K, Røislien J, Solyga V, Lund CG, Bache KG. Ultraearly thrombolysis by an anesthesiologist in a mobile stroke unit: A prospective, controlled intervention study. Eur J Neurol 2021; 28:2488-2496. [PMID: 33890385 DOI: 10.1111/ene.14877] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute stroke treatment in mobile stroke units (MSU) is feasible and reduces time-to-treatment, but the optimal staffing model is unknown. We wanted to explore if integrating thrombolysis of acute ischemic stroke (AIS) in an anesthesiologist-based emergency medical services (EMS) reduces time-to-treatment and is safe. METHODS A nonrandomized, prospective, controlled intervention study. INCLUSION CRITERIA age ≥18 years, nonpregnant, stroke symptoms with onset ≤4 h. The MSU staffing is inspired by the Norwegian Helicopter Emergency Medical Services crew with an anesthesiologist, a paramedic-nurse and a paramedic. Controls were included by conventional ambulances in the same catchment area. Primary outcome was onset-to-treatment time. Secondary outcomes were alarm-to-treatment time, thrombolytic rate and functional outcome. Safety outcomes were symptomatic intracranial hemorrhage and mortality. RESULTS We included 440 patients. MSU median (IQR) onset-to-treatment time was 101 (71-155) minutes versus 118 (90-176) minutes in controls, p = 0.007. MSU median (IQR) alarm-to-treatment time was 53 (44-65) minutes versus 74 (63-95) minutes in controls, p < 0.001. Golden hour treatment was achieved in 15.2% of the MSU patients versus 3.7% in the controls, p = 0.005. The thrombolytic rate was higher in the MSU (81% vs 59%, p = 0.001). MSU patients were more often discharged home (adjusted OR [95% CI]: 2.36 [1.11-5.03]). There were no other significant differences in outcomes. CONCLUSIONS Integrating thrombolysis of AIS in the anesthesiologist-based EMS reduces time-to-treatment without negatively affecting outcomes. An MSU based on the EMS enables prehospital assessment of acute stroke in addition to other medical and traumatic emergencies and may facilitate future implementation.
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Affiliation(s)
- Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Henriette S Jaeger
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Lars H Tveit
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Maren R Hov
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway.,Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | | | - Jo Røislien
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Volker Solyga
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway
| | | | - Kristi G Bache
- The Norwegian Air Ambulance Foundation, Oslo, Norway.,Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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26
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El-Wahsh S, Dunkerton S, Ang T, Winters HS, Delcourt C. Current perspectives on neuroimaging techniques used to identify stroke mimics in clinical practice. Expert Rev Neurother 2021; 21:517-531. [PMID: 33787426 DOI: 10.1080/14737175.2021.1911650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Urgent clinical assessment and brain imaging are essential for differentiating stroke mimics from stroke and to avoid unnecessary initiation of reperfusion and other therapies in stroke mimic patients. AREAS COVERED In this article, the authors will review acute stroke imaging and then the imaging patterns of the most common stroke mimics. The authors have focused our review on brain CT scan, and more specifically CT perfusion, as this is the most commonly available and emerging tool in emergency settings. The authors also provide information on acute brain MRI and MR perfusion. EXPERT OPINION Imaging can contribute to the detection and diagnosis of acute stroke mimics. Knowledge of imaging findings in different stroke mimics can help distinguish these from patients with stroke who require timely reperfusion therapy. CT and MRI perfusion and diffusion-weighted imaging (DWI) MRI are useful imaging modalities for the assessment of acute stroke patients as they provide more accurate information than plain CT scan. Some of these modalities should be available in the emergency setting. The authors recommended CT perfusion as a useful tool for stroke management and differentiation with stroke mimics.
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Affiliation(s)
- Shadi El-Wahsh
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Sophie Dunkerton
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Timothy Ang
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Hugh Stephen Winters
- Neurology Department, Royal Prince Alfred Hospital, the University of Sydney, Sydney, New South Wales, Australia
| | - Candice Delcourt
- The George Institute for Global Health, The University of New South Wales, Sydney, Australia.,Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, New South Wales, Australia
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27
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Waller J, Kaur P, Tucker A, Amer R, Bae S, Kogler A, Umair M. The benefit of intravenous thrombolysis prior to mechanical thrombectomy within the therapeutic window for acute ischemic stroke. Clin Imaging 2021; 79:3-7. [PMID: 33862545 DOI: 10.1016/j.clinimag.2021.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/21/2021] [Accepted: 03/18/2021] [Indexed: 11/19/2022]
Abstract
The increase in risk for acute ischemic stroke (AIS) with age is well established. If not treated properly and promptly, AIS can result in permanent neurological damage and even death. This literature review assesses the clinical outcomes of AIS patients treated with both intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) compared to those treated solely with mechanical thrombectomy. Randomized controlled trials (RCTs) and meta-analyses published from 2015 to 2020 and available on PubMed were selected for review, and their quantitative and qualitative findings were extrapolated and summarized. Post-hoc analyses from ASTER and ETIS trials were reviewed as well as the impact of combined therapy and monotherapy on large vessel occlusions (LVO). Clinical outcomes in all examined trials demonstrated significant successful reperfusion as well as a higher rate of functional independence at 90 days for IVT prior to MT. Concerns of thrombus fragility, safety and cost effectiveness of dual therapy are also addressed. Based on these findings, we recommend the use of IVT as a pretreatment procedure to MT for AIS when eligible for IVT. Recent articles further strengthen this recommendation and provide new insights that IVT prior to MT is especially beneficial for patients presenting with multiple LVOs localized to the anterior intracranial circulation. Additional multi-center RCTs are necessary for further analysis of statistical outcomes demonstrating mixed effects.
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Affiliation(s)
- Joseph Waller
- Drexel University College of Medicine, 2900 W Queen Ln, PA 19129, United States of America.
| | - Parveer Kaur
- Vassar College, 124 Raymond Avenue, NY 12604, United States of America
| | - Amy Tucker
- Loyola University Chicago, 1032 W Sheridan Rd, IL 60660, United States of America
| | - Rami Amer
- Drexel University College of Medicine, 2900 W Queen Ln, PA 19129, United States of America
| | - Sonu Bae
- Ohio State University School of Medicine, 370 W 9th Ave, Columbus, OH 43210, United States of America
| | - Ann Kogler
- Drexel University College of Medicine, 2900 W Queen Ln, PA 19129, United States of America
| | - Muhammad Umair
- Northwestern University Feinberg School of Medicine, Department of Radiology, 676 N St Clair St, Chicago, IL 60611, United States of America
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28
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Kühne Escolà J, Nagel S, Verez Sola C, Doroszewski E, Jaschonek H, Gutschalk A, Gumbinger C, Purrucker JC. Diagnostic Accuracy in Teleneurological Stroke Consultations. J Clin Med 2021; 10:jcm10061170. [PMID: 33799590 PMCID: PMC7998723 DOI: 10.3390/jcm10061170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The accuracy of diagnosing acute cerebrovascular disease via a teleneurology service and the characteristics of misdiagnosed patients are insufficiently known. Methods: A random sample (n = 1500) of all teleneurological consultations conducted between July 2015 and December 2017 was screened. Teleneurological diagnosis and hospital discharge diagnosis were compared. Diagnoses were then grouped into two main categories: cerebrovascular disease (CVD) and noncerebrovascular disease. Test characteristics were calculated. Results: Out of 1078 consultations, 52% (n = 561) had a final diagnosis of CVD. Patients with CVD could be accurately identified via teleneurological consultation (sensitivity 95.2%, 95% CI 93.2–96.8), but we observed a tendency towards false-positive diagnosis (specificity 77.4%, 95% CI 73.6–80.8). Characteristics of patients with a false-negative CVD diagnosis were similar to those of patients with a true-positive diagnosis, but patients with a false-negative CVD diagnosis had ischemic heart disease less frequently. In retrospect, one patient would have been considered a candidate for intravenous thrombolysis (0.2%). Conclusions: Teleneurological consultations are accurate for identifying patients with CVD, and there is a very low rate of missed candidates for thrombolysis. Apart from a lower prevalence of ischemic heart disease, characteristics of “stroke chameleons” were similar to those of correctly identified CVD patients.
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29
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Tsivgoulis G, Kargiotis O, De Marchis G, Kohrmann M, Sandset EC, Karapanayiotides T, de Sousa DA, Sarraj A, Safouris A, Psychogios K, Vadikolias K, Leys D, Schellinger PD, Alexandrov AV. Off-label use of intravenous thrombolysis for acute ischemic stroke: a critical appraisal of randomized and real-world evidence. Ther Adv Neurol Disord 2021; 14:1756286421997368. [PMID: 33737956 PMCID: PMC7934037 DOI: 10.1177/1756286421997368] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
Intravenous thrombolysis (IVT) represents the only systemic reperfusion therapy able to reverse neurological deficit in patients with acute ischemic stroke (AIS). Despite its effectiveness in patients with or without large vessel occlusion, it can be offered only to a minority of them, because of the short therapeutic window and additional contraindications derived from stringent but arbitrary inclusion and exclusion criteria used in landmark randomized controlled clinical trials. Many absolute or relative contraindications lead to disparities between the official drug label and guidelines or expert recommendations. Based on recent advances in neuroimaging and evidence from cohort studies, off-label use of IVT is increasingly incorporated into the daily practice of many stroke centers. They relate to extension of therapeutic time windows, and expansion of indications in co-existing conditions originally listed in exclusion criteria, such as use of alternative thrombolytic agents, pre-treatment with antiplatelets, anticoagulants or low molecular weight heparins. In this narrative review, we summarize recent randomized and real-world data on the safety and efficacy of off-label use of IVT for AIS. We also make some practical recommendations to stroke physicians regarding the off-label use of thrombolytic agents in complex and uncommon presentations of AIS or other conditions mimicking acute cerebral ischemia. Finally, we provide guidance on the risks and benefits of IVT in numerous AIS subgroups, where equipoise exists and guidelines and treatment practices vary.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, Iras 39, Gerakas Attikis, Athens 15344, Greece
| | | | - Gianmarco De Marchis
- Neurology and Stroke Center, Department of Clinical Research, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Martin Kohrmann
- Department of Neurology, Universitätsklinikum Essen, Essen, Germany
| | | | - Theodore Karapanayiotides
- Department of Neurology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Diana Aguiar de Sousa
- Department of Neurosciences (Neurology), Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Amrou Sarraj
- Department of Neurology, The University of Texas at Houston, Houston, TX, USA
| | - Apostolos Safouris
- Second Department of Neurology, National & Kapodistiran University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
| | | | - Konstantinos Vadikolias
- Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Didier Leys
- Department of Neurology (Stroke Unit), Lille Neuroscience and Cognition, Degenerative and Vascular Cognitive Disorders, University of Lille, INSERM (U-1172), Lille, France
| | - Peter D Schellinger
- Department of Neurology, Johannes Wesling Medical Center Minden, UK RUB Minden, Germany
| | - Andrei V Alexandrov
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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30
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Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021; 6:I-LXII. [PMID: 33817340 DOI: 10.1177/2396987321989865] [Citation(s) in RCA: 430] [Impact Index Per Article: 143.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/27/2020] [Indexed: 02/06/2023] Open
Abstract
Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.
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Affiliation(s)
- Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Heinrich Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Gian Marco De Marchis
- University Hospital of Basel & University of Basel, Department for Neurology & Stroke Center, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Chiara Padiglioni
- Neurology Unit-Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hopital Sainte-Anne, Université de Paris, Paris, France.,INSERM U1266.,FHU NeuroVasc
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31
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Ippen FM, Walter F, Hametner C, Gumbinger C, Nagel S, Purrucker JC, Mundiyanapurath S. Age-Dependent Differences in the Rate and Symptoms of TIA Mimics in Patients Presenting With a Suspected TIA to a Neurological Emergency Room. Front Neurol 2021; 12:644223. [PMID: 33658979 PMCID: PMC7917180 DOI: 10.3389/fneur.2021.644223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 01/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Transient ischemic attack (TIA) needs further diagnostic evaluation to prevent future ischemic stroke. However, prophylaxis can be harmful in elderly if the diagnosis is wrong. We aimed at characterizing differences in TIA mimics in younger and older patients to enhance diagnostic accuracy in elderly patients. Methods: In a dedicated neurological emergency room (nER) of a tertiary care University hospital, patients with transient neurological symptoms suspicious of TIA (<24 h) were retrospectively analyzed regarding their final diagnoses and their symptoms. These parameters were compared between patients aged 18-70 and >70 years using descriptive, univariable, and multivariable statistics. Results: From November 2018 until August 2019, 386 consecutive patients were included. 271 (70%) had cardiovascular risk factors and all patients received cerebral imaging, mostly CT [376 (97%)]. There was no difference in the rate of diagnosed TIA between the age groups [85 (46%) vs. 58 (39%); p = 0.213].TIA mimics in the elderly were more often internal medicine diseases [35 (19%) vs. 7 (5%); p < 0.001] and epileptic seizures [48 (26%) vs. 24 (16%); p = 0.032] but less often migraine [2 (1%) vs. 20 (13%); p < 0.001]. The most frequent symptoms in all patients were aphasia and dysarthria [107 (28%) and 92 (24%)]. Sensory impairments were less frequent in elderly patients [23 (11%) vs. 54 (30%); p < 0.001]. Impaired consciousness and orientation were independent predictors for TIA mimics (p < 0.001) whereas facial palsy (p < 0.001) motor weakness (p < 0.001), dysarthria (p = 0.022) and sensory impairment (p < 0.001) were independent predictors of TIA. Conclusion: TIA mimics in elderly patients are more likely to be internal medicine diseases and epilepsy compared to younger patients. Excluding internal medicine diseases seems to be important in elderly patients. Facial palsy, motor weakness, dysarthria and sensory impairment are associated with TIA.
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Affiliation(s)
| | - Fabian Walter
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Hametner
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Gumbinger
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan C Purrucker
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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Psychogios K, Kargiotis O, Safouris A, Magoufis G, Gelagoti M, Bonakis A, Stamboulis E, Tsivgoulis G. Perfusion imaging averting intravenous thrombolysis in stroke mimics. Neurol Sci 2021; 42:2591-2594. [PMID: 33543422 DOI: 10.1007/s10072-021-05090-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 01/23/2021] [Indexed: 12/28/2022]
Affiliation(s)
- Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Ethn. Makariou 9, PC 18547, N. Faliro, Piraeus, Greece.
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece.
| | - Odysseas Kargiotis
- Stroke Unit, Metropolitan Hospital, Ethn. Makariou 9, PC 18547, N. Faliro, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Ethn. Makariou 9, PC 18547, N. Faliro, Piraeus, Greece
| | - Georgios Magoufis
- Stroke Unit, Metropolitan Hospital, Ethn. Makariou 9, PC 18547, N. Faliro, Piraeus, Greece
| | - Maria Gelagoti
- Stroke Unit, Metropolitan Hospital, Ethn. Makariou 9, PC 18547, N. Faliro, Piraeus, Greece
| | - Anastasios Bonakis
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
| | - Eleftherios Stamboulis
- Stroke Unit, Metropolitan Hospital, Ethn. Makariou 9, PC 18547, N. Faliro, Piraeus, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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Role of neuroimaging before reperfusion therapy. Part 1 - IV thrombolysis - Review. Rev Neurol (Paris) 2021; 177:908-918. [PMID: 33455833 DOI: 10.1016/j.neurol.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/25/2020] [Accepted: 10/05/2020] [Indexed: 11/22/2022]
Abstract
This review paper summarises the yield of the different imaging modalities in the evaluation of patients for IV thrombolysis. Non-contrast CT and CTA or brain MRI combined with MRA are the recommended sequences for the evaluation of patients within the 4.5 hours time window. Multimodal MRI (DWI/PWI), and more recently, CT perfusion, offer reliable surrogate of salvageable penumbra, the target mismatch, which is now currently used as selection criteria for revascularisation treatment in an extended time window. Those sequences may also help the physician for the management of other limited cases when the diagnosis of acute ischemic stroke is difficult. Another approach the DWI/FLAIR mismatch has been proposed to identify among wake-up stroke patients those who have been experiencing an acute ischemic stroke evolving from less than 4.5hrs. Other biomarkers, such as the clot imaging on MRI and CT, help to predict the recanalisation rate after IVT, while the impact of the presence microbleeds on MRI remains to be determined.
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Lucas L, Gariel F, Menegon P, Aupy J, Thomas B, Tourdias T, Sibon I, Renou P. Acute Ischemic Stroke or Epileptic Seizure? Yield of CT Perfusion in a "Code Stroke" Situation. AJNR Am J Neuroradiol 2021; 42:49-56. [PMID: 33431502 DOI: 10.3174/ajnr.a6925] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 08/27/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The clinical differentiation between acute ischemic stroke and epileptic seizure may be challenging, and making the correct diagnosis could avoid unnecessary reperfusion therapy. We examined the accuracy of CTP in discriminating epileptic seizures from acute ischemic stroke without identified arterial occlusion. MATERIALS AND METHODS We retrospectively identified consecutive patients in our emergency department who underwent CTP in the 4.5 hours following the development of an acute focal neurologic deficit who were discharged with a final diagnosis of acute ischemic stroke or epileptic seizure. RESULTS Among 95 patients, the final diagnosis was epileptic seizure in 45 and acute ischemic stroke in 50. CTP findings were abnormal in 73% of the patients with epileptic seizure and 40% of those with acute ischemic stroke. Hyperperfusion was observed more frequently in the seizure group (36% versus 2% for acute ischemic stroke) with high specificity (98%) but low sensitivity (35%) for the diagnosis of epileptic seizure. Hypoperfusion was found in 38% of cases in each group and was not confined to a vascular territory in 24% of patients in the seizure group and 2% in the acute ischemic stroke group. The interobserver agreement was good (κ = 0.60) for hypo-, hyper-, and normoperfusion patterns and moderate (κ = 0.41) for the evaluation of vascular systematization. CONCLUSIONS CTP patterns helped to differentiate acute ischemic stroke from epileptic seizure in a "code stroke" situation. Our results indicate that a hyperperfusion pattern, especially if not restricted to a vascular territory, may suggest reconsideration of intravenous thrombolysis therapy.
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Affiliation(s)
- L Lucas
- From the Department of Neurology (L.L., I.S., P.R.), Stroke Unit .,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - F Gariel
- Departments of Neuroradiology (F.G., B.T., T.T.)
| | | | - J Aupy
- Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France.,Institut des Matériaux Jean Rouxel, (J.A.), Union Mutualiste Retraite, Centre national de la recherche scientifique, University of Bordeaux, Bordeaux, France
| | - B Thomas
- Departments of Neuroradiology (F.G., B.T., T.T.).,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - T Tourdias
- Departments of Neuroradiology (F.G., B.T., T.T.).,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - I Sibon
- From the Department of Neurology (L.L., I.S., P.R.), Stroke Unit.,Epileptology, and Clinical Neuroscience (L.L., J.A., B.T., T.T., I.S.), University of Bordeaux, Bordeaux, France
| | - P Renou
- From the Department of Neurology (L.L., I.S., P.R.), Stroke Unit
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Wang Y, Wu X, Zhu C, Mossa-Basha M, Malhotra A. Bridging Thrombolysis Achieved Better Outcomes Than Direct Thrombectomy After Large Vessel Occlusion: An Updated Meta-Analysis. Stroke 2020; 52:356-365. [PMID: 33302795 DOI: 10.1161/strokeaha.120.031477] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The utility and necessity of pretreatment with intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) remains an issue of strong debate. This study aims to compare the outcomes of bridging thrombolysis (BT, IVT+MT) with direct MT (d-MT) after large vessel ischemic stroke based on the most up-to-date evidence. MEDLINE, EMBASE, Scopus, and the Cochrane Library from January 2017 to June 2020 were searched for studies that directly compared the outcomes of the 2 strategies. Methodological quality was assessed using the Quality in Prognostic Studies tool. Combined estimates of odds ratios (ORs) of BT versus d-MT were derived. Multiple subgroup analyses were performed, especially for IVT-eligible patients. Thirty studies involving 7191 patients in the BT group and 4891 patients in the d-MT group were included. Methodological quality was generally high. Compared with patients in the d-MT group, patients in the BT group showed significantly better functional independence (modified Rankin Scale score 0-2) at 90 days (OR=1.43 [95% CI, 1.28-1.61]), had lower mortality at 90 days (OR=0.67 [95% CI, 0.60-0.75]), and achieved higher successful recanalization (modified Thrombolysis in Cerebral Ischemia score 2b-3) rate (OR=1.23 [95% CI, 1.07-1.42]). No significant difference was detected in the occurrence of symptomatic intracranial hemorrhage between 2 groups (OR=1.01 [95% CI, 0.86-1.19]). Subgroup analysis showed that functional independence frequency remained significantly higher in BT group regardless of IVT eligibility or study design. Compared with d-MT, bridging with IVT led to better clinical outcomes, lower mortality at 90 days, and higher successful recanalization rates, without increasing the risk of near-term hemorrhagic complications. The benefits of BT based on this most recent literature evidence support the current guidelines of using BT.
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Affiliation(s)
- Yuting Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu (Y.W.)
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, University of California, San Francisco (X.W.)
| | - Chengcheng Zhu
- Department of Radiology, University of Washington School of Medicine, Seattle (C.Z., M.M.-B.)
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, Seattle (C.Z., M.M.-B.)
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine and Yale University, New Haven, CT (A.M.)
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Ostman C, Garcia-Esperon C, Lillicrap T, Tomari S, Holliday E, Levi C, Bivard A, Parsons MW, Spratt NJ. Multimodal Computed Tomography Increases the Detection of Posterior Fossa Strokes Compared to Brain Non-contrast Computed Tomography. Front Neurol 2020; 11:588064. [PMID: 33329332 PMCID: PMC7714905 DOI: 10.3389/fneur.2020.588064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/19/2020] [Indexed: 11/13/2022] Open
Abstract
Aims: Multimodal computed tomography (mCT) (non-contrast CT, CT angiography, and CT perfusion) is not routinely used to assess posterior fossa strokes. We described the area under the curve (AUC) of brain NCCT, WB-CTP automated core-penumbra maps and comprehensive CTP analysis (automated core-penumbra maps and all perfusion maps) for posterior fossa strokes. Methods: We included consecutive patients with signs and symptoms of posterior fossa stroke who underwent acute mCT and follow up magnetic resonance diffusion weighted imaging (DWI). Multimodal CT images were reviewed blindly and independently by two stroke neurologists and area under the receiver operating characteristic curve (AUC) was used to compare imaging modalities. Results: From January 2014 to December 2019, 83 patients presented with symptoms suggestive of posterior fossa strokes and had complete imaging suitable for inclusion (49 posterior fossa strokes and 34 DWI negative patients). For posterior fossa strokes, comprehensive CTP analysis had an AUC of 0.68 vs. 0.62 for automated core-penumbra maps and 0.55 for NCCT. For cerebellar lesions >5 mL, the AUC was 0.87, 0.81, and 0.66, respectively. Conclusion: Comprehensive CTP analysis increases the detection of posterior fossa lesions compared to NCCT and should be implemented as part of the routine imaging assessment in posterior fossa strokes.
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Affiliation(s)
- Cecilia Ostman
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia
| | - Thomas Lillicrap
- Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Shinya Tomari
- Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia
| | - Elizabeth Holliday
- Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher Levi
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.,Maridulu Budyari Gumal, The Sydney Partnership for Health Education Research & Enterprise (SPHERE), University of New South Wales, Sydney, NSW, Australia
| | - Andrew Bivard
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, NSW, Australia
| | - Mark W Parsons
- Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia.,Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, NSW, Australia.,UNSW South Western Sydney Clinical School, University of New South Wales and Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Neil J Spratt
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia.,Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW, Australia
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37
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Albakr A, Ishaque N, Aljaafari D, Sairafi SN. Contrast-Induced Transient Neurological Symptoms Following Percutaneous Coronary Intervention: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e926956. [PMID: 33186339 PMCID: PMC7672509 DOI: 10.12659/ajcr.926956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Transient neurological symptoms after a percutaneous coronary intervention (PCI) are not uncommon manifestations. In clinical practice, the development of these symptoms might be a warning sign for PCI-related ischemic or hemorrhagic stroke. However, there is a reported risk of contrast-induced neurological injury (CINI) after PCI, which results in a broad spectrum of transient and benign neurological symptoms. Advanced age, renal disease, diabetes, hypertension, and brain parenchymal lesions are risk factors for CINI. CASE REPORT A 78-year-old man with diabetes and impaired renal function developed left-sided hemiparesis and dysarthria within one hour of PCI. Non-contrast CT head showed hyperdense lesions in both frontal lobes, while the susceptibility-weighted sequence of magnetic resonance imaging (SWI-MRI) excludes hemorrhage. Hemodialysis had to be started for fast contrast clearance, and he had recovered completely within 24 hours. CONCLUSIONS This case demonstrates that CINI is an important differential diagnosis that cardiologists and neurologists must be familiar with, especially for high-risk patients. The prognosis is good; whether an appropriate contrast's dose or type for PCI or a need for early hemodialysis to avoid CINI in those patients is unclear.
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Affiliation(s)
- Aishah Albakr
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Noman Ishaque
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Danah Aljaafari
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sabah N Sairafi
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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38
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Characteristics and Outcomes of Patients who Refuse Intravenous Thrombolysis for Acute Ischemic Stroke - The San Diego Experience. J Stroke Cerebrovasc Dis 2020; 29:105137. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/29/2020] [Accepted: 07/06/2020] [Indexed: 11/18/2022] Open
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39
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Wadhwa A, Joundi RA, Menon B. Clinical considerations and assessment of risk factors when choosing endovascular thrombectomy for acute stroke. Expert Rev Cardiovasc Ther 2020; 18:541-556. [PMID: 32686967 DOI: 10.1080/14779072.2020.1798229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The advent of endovascular thrombectomy (EVT) has been a game changer for the management of acute ischemic stroke due to large vessel occlusion. However, the selection of suitable candidates for EVT remains a significant challenge. AREAS COVERED This review focuses on the clinical, radiological, and procedural considerations for EVT in acute stroke that assist in optimal patient selection. EXPERT OPINION All patients presenting with significant clinical deficits with treatable occlusions, who have salvageable brain tissue at presentation might benefit from treatment up to twenty-four hours from symptom onset. Neuroimaging tools form the backbone for this decision making.
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Affiliation(s)
- Ankur Wadhwa
- Calgary Stroke Program, University of Calgary, Foot Hills Medical Center , Calgary, AB, Canada
| | - Raed A Joundi
- Calgary Stroke Program, University of Calgary, Foot Hills Medical Center , Calgary, AB, Canada
| | - Bijoy Menon
- Clinical Neurosciences, University of Calgary, Foot Hills Medical Center , Calgary, AB, Canada
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40
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Tu TM, Tan GZ, Saffari SE, Wee CK, Chee DJMS, Tan C, Lim HC. External validation of stroke mimic prediction scales in the emergency department. BMC Neurol 2020; 20:269. [PMID: 32635897 PMCID: PMC7339435 DOI: 10.1186/s12883-020-01846-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/28/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Acute ischemic stroke is a time-sensitive emergency where accurate diagnosis is required promptly. Due to time pressures, stroke mimics who present with similar signs and symptoms as acute ischemic stroke, pose a diagnostic challenge to the emergency physician. With limited access to investigative tools, clinical prediction, tools based only on clinical features, may be useful to identify stroke mimics. We aim to externally validate the performance of 4 stroke mimic prediction scales, and derive a novel decision tree, to improve identification of stroke mimics. METHODS We performed a retrospective cross-sectional study at a primary stroke centre, served by a telestroke hub. We included consecutive patients who were administered intravenous thrombolysis for suspected acute ischemic stroke from January 2015 to October 2017. Four stroke mimic prediction tools (FABS, simplified FABS, Telestroke Mimic Score and Khan Score) were rated simultaneously, using only clinical information prior to administration of thrombolysis. The final diagnosis was ascertained by an independent stroke neurologist. Area under receiver operating curve (AUROC) analysis was performed. A classification tree analysis was also conducted using variables which were found to be significant in the univariate analysis. RESULTS Telestroke Mimic Score had the highest discrimination for stroke mimics among the 4 scores tested (AUROC = 0.75, 95% CI = 0.63-0.87). However, all 4 scores performed similarly (DeLong p > 0.05). Telestroke Mimic Score had the highest sensitivity (91.3%), while Khan score had the highest specificity (88.2%). All 4 scores had high positive predictive value (88.1 to 97.5%) and low negative predictive values (4.7 to 32.3%). A novel decision tree, using only age, presence of migraine and psychiatric history, had a higher prediction performance (AUROC = 0.80). CONCLUSION Four tested stroke mimic prediction scales performed similarly to identify stroke mimics in the emergency setting. A novel decision tree may improve the identification of stroke mimics.
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Affiliation(s)
- Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore. .,Singhealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, Singapore.
| | - Guan Zhong Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University of Singapore, Singapore, Singapore
| | - Seyed Ehsan Saffari
- Centre of Quantitative Medicine, Office of Research, Duke-NUS Medical School, Singapore, Singapore
| | - Chee Keong Wee
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | | | - Camlyn Tan
- Accident and Emergency Department, Changi General Hospital, Singapore, Singapore
| | - Hoon Chin Lim
- Accident and Emergency Department, Changi General Hospital, Singapore, Singapore
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41
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Affiliation(s)
- Bruce C.V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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42
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McKay EC, Beck JS, Khoo SK, Dykema KJ, Cottingham SL, Winn ME, Paulson HL, Lieberman AP, Counts SE. Peri-Infarct Upregulation of the Oxytocin Receptor in Vascular Dementia. J Neuropathol Exp Neurol 2020; 78:436-452. [PMID: 30990880 DOI: 10.1093/jnen/nlz023] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Vascular dementia (VaD) is cognitive decline linked to reduced cerebral blood perfusion, yet there are few therapeutic options to protect cognitive function following cerebrovascular accidents. The purpose of this study was to profile gene expression changes unique to VaD to identify and characterize disease relevant changes that could offer clues for future therapeutic direction. Microarray-based profiling and validation studies of postmortem frontal cortex samples from VaD, Alzheimer disease, and age-matched control subjects revealed that the oxytocin receptor (OXTR) was strongly and differentially upregulated in VaD. Further characterization in fixed tissue from the same cases showed that OXTR upregulation occurs de novo around and within microinfarcts in peri-infarct reactive astrocytes as well as within vascular profiles, likely on microvascular endothelial cells. These results indicate that increased OXTR expression in peri-infarct regions may be a specific response to microvascular insults. Given the established OXTR signaling cascades that elicit antioxidant, anti-inflammatory, and pro-angiogenic responses, the present findings suggest that de novo OXTR expression in the peri-infarct space is a tissue-protective response by astroglial and vascular cells in the wake of ischemic damage that could be exploited as a therapeutic option for the preservation of cognition following cerebrovascular insults.
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Affiliation(s)
- Erin C McKay
- Department of Translational Science and Molecular Medicine, Michigan State University, Grand Rapids, Michigan.,Neuroscience Program, Michigan State University, East Lansing, Michigan
| | - John S Beck
- Department of Translational Science and Molecular Medicine, Michigan State University, Grand Rapids, Michigan
| | - Sok Kean Khoo
- Department of Cell and Molecular Biology, Grand Valley State University, Grand Rapids, Michigan
| | - Karl J Dykema
- Bioinformatics and Biostatistics Core, Van Andel Research Institute, Grand Rapids, Michigan
| | - Sandra L Cottingham
- Department of Pathology, Spectrum Health and Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Mary E Winn
- Bioinformatics and Biostatistics Core, Van Andel Research Institute, Grand Rapids, Michigan
| | - Henry L Paulson
- Department of Neurology, University of Michigan, Ann Arbor, Michigan.,Michigan Alzheimer's Disease Core Center, Ann Arbor, Michigan
| | - Andrew P Lieberman
- Department of Pathology, University of Michigan, Ann Arbor, Michigan.,Michigan Alzheimer's Disease Core Center, Ann Arbor, Michigan
| | - Scott E Counts
- Department of Translational Science and Molecular Medicine, Michigan State University, Grand Rapids, Michigan.,Neuroscience Program, Michigan State University, East Lansing, Michigan.,Michigan Alzheimer's Disease Core Center, Ann Arbor, Michigan.,Department of Family Medicine, Michigan State University, Grand Rapids, Michigan.,Hauenstein Neurosciences Center, Mercy Health Saint Mary's Hospital, Grand Rapids, Michigan
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Primary endovascular treatment for acute ischemic stroke in teenage patients: a short case series. Neuroradiology 2020; 62:851-860. [PMID: 32307558 DOI: 10.1007/s00234-020-02421-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/26/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE To analyze the safety and efficacy of primary endovascular treatment (EVT) for acute ischemic stroke (AIS) in patients younger than 18 years of age. METHODS Review of 4 patients < 18 years of age with AIS, prospectively enrolled in an electronic database registry for acute ischemic stroke patients who underwent thrombectomy at tertiary centers, from January 2011 to February 2017. Clinical and imaging data were analyzed. RESULTS All patients were female. Patients 1 to 4 were 14, 13, 16, and 13 years old, respectively. Patients 1 and 3 had left middle cerebral artery occlusion, patient 2 basilar occlusion, and patient 4 right tandem occlusion. Mean NIHSS score was 13 (7-19) on arrival and 4 (0-5) at 24 h. Patient 2 had Osler-Weber-Rendu disease and patient 4 a previously surgically repaired complete atrioventricular canal. All patients presented with clinical-radiological mismatch. CT/CTA was used in patients 1 and 4 and MRI/MRA in patients 2 and 3. Stent retriever was used in 3 patients (patients 1, 3, and 4) and direct aspiration first-pass technique in 1 (patient 2). All 4 procedures resulted in successful recanalization and 3-month functional independence. CONCLUSION Primary EVT is reported in patients 13 to 16 years of age with AIS due to large vessel occlusion and clinical-radiological mismatch. Procedures were safe and effective with prompt recanalization and good clinical outcome.
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44
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Antonucci MU, Yazdani M. A Helpful Tool in Diagnosing Stroke Mimics: Arterial Spin Labeled Perfusion Magnetic Resonance Imaging. J Emerg Med 2020; 58:439-443. [PMID: 32197894 DOI: 10.1016/j.jemermed.2019.12.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 12/10/2019] [Accepted: 12/16/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prompt and effective management of acute ischemic stroke in the emergency setting requires a high level of suspicion and accurate diagnosis. Conversely, identifying stroke mimics can be challenging, given the similarity of their clinical symptomatology, the necessary rapid assessment and triage, and the overall frenetic pace inherent in the goal of rapid thrombolysis ("time is brain"). CASE REPORT We describe a case that involves an elderly patient with acute hemiplegia and dysarthria. Given these concerning symptoms, and multiple preexisting cerebrovascular risk factors (including paroxysmal atrial fibrillation), a "stroke alert" was issued. Imaging was negative for infarct and she was ultimately diagnosed with hemiplegic migraine based on her symptoms and impressive findings on a novel magnetic resonance sequence called arterial spin labeled (ASL) perfusion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Identifying a nonischemic etiology in a presumed stroke patient, while often difficult, can obviate unnecessary treatment, improve patient care, and promote appropriate resource allocation. As imaging and treatment of cerebrovascular disease advances, the optimization of multidisciplinary care should incorporate neuroradiologists informing and availing their clinical colleagues of applications of an ever-expanding imaging armamentarium. This case is an excellent example of both a common challenging stroke mimic and the potential benefits of ASL perfusion imaging in refining and expediting accurate diagnosis. In addition, it serves as a more general introduction to the particular strengths of this noninvasive, noncontrast magnetic resonance technique, which can be employed to assess varied emergent neuropathology.
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Affiliation(s)
- Michael U Antonucci
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
| | - Milad Yazdani
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina
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45
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Willenberg R, Leung B, Song S, Dumitrascu OM, Schlick K, Lyden P. Munchausen Syndrome by Tissue Plasminogen Activator: Patients Seeking Thrombolytic Administration. Neurol Clin Pract 2020; 11:64-68. [PMID: 33968474 DOI: 10.1212/cpj.0000000000000828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/26/2020] [Indexed: 11/15/2022]
Abstract
Purpose of Review Munchausen syndrome by tissue plasminogen activator (tPA) is a phenomenon we describe as patients exhibiting factitious symptoms to assume the role of the sick patient, desiring and received tPA, with no alternative diagnosis or secondary gain to better account for their presentation. To illustrate this phenomenon and its magnitude, we present a series of cases of Munchausen syndrome by tPA, prevalence in our stroke center, and highlight one illustrative case. Recent Findings Of 335 cases with tPA administration over 29 months, 10 were confirmed as Munchausen syndrome by tPA, reflecting a 3.0% prevalence in our stroke center. Summary Munchausen syndrome by tPA is an underappreciated phenomenon encountered in evaluating patients with acute stroke symptoms. Administering tPA in Munchausen syndrome poses an ethical dilemma because standard of care favors rapid tPA administration, but administration can cause harm, burdens the healthcare system, and does not treat the patient's Munchausen syndrome.
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Affiliation(s)
- Rafer Willenberg
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Bo Leung
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Shlee Song
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Oana M Dumitrascu
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Konrad Schlick
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Patrick Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA
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46
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Kuhrij L, van Zwet E, van den Berg-Vos R, Nederkoorn P, Marang-van de Mheen PJ. Enhancing feedback on performance measures: the difference in outlier detection using a binary versus continuous outcome funnel plot and implications for quality improvement. BMJ Qual Saf 2020; 30:38-45. [PMID: 32034014 PMCID: PMC7788228 DOI: 10.1136/bmjqs-2019-009929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 01/06/2020] [Accepted: 01/30/2020] [Indexed: 01/01/2023]
Abstract
Background Hospitals and providers receive feedback information on how their performance compares with others, often using funnel plots to detect outliers. These funnel plots typically use binary outcomes, and continuous variables are dichotomised to fit this format. However, information is lost using a binary measure, which is only sensitive to detect differences in higher values (the tail) rather than the entire distribution. This study therefore aims to investigate whether different outlier hospitals are identified when using a funnel plot for a binary vs a continuous outcome. This is relevant for hospitals with suboptimal performance to decide whether performance can be improved by targeting processes for all patients or a subgroup with higher values. Methods We examined the door-to-needle time (DNT) of all (6080) patients with acute ischaemic stroke treated with intravenous thrombolysis in 65 hospitals in 2017, registered in the Dutch Acute Stroke Audit. We compared outlier hospitals in two funnel plots: the median DNT versus the proportion of patients with substantially delayed DNT (above the 90th percentile (P90)), whether these were the same or different hospitals. Two sensitivity analyses were performed using the proportion above the median and a continuous P90 funnel plot. Results The median DNT was 24 min and P90 was 50 min. In the binary funnel plot for the proportion of patients above P90, 58 hospitals had average performance, whereas in the funnel plot around the median 14 of these hospitals had significantly higher median DNT (24%). These hospitals can likely improve their DNT by focusing on care processes for all patients, not shown by the binary outcome funnel plot. Similar results were shown in sensitivity analyses. Conclusion Using funnel plots for continuous versus binary outcomes identify different outlier hospitals, which may enhance hospital feedback to direct more targeted improvement initiatives.
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Affiliation(s)
- Laurien Kuhrij
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Erik van Zwet
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Renske van den Berg-Vos
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands.,Department of Neurology, OLVG, Amsterdam, Noord-Holland, The Netherlands
| | - Paul Nederkoorn
- Department of Neurology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Amlie-Lefond C, Shaw DW, Cooper A, Wainwright MS, Kirton A, Felling RJ, Abraham MG, Mackay MT, Dowling MM, Torres M, Rivkin MJ, Grabowski EF, Lee S, Kurz JE, McMillan HJ, Barry D, Lee-Eng J, Ichord RN. Risk of Intracranial Hemorrhage Following Intravenous tPA (Tissue-Type Plasminogen Activator) for Acute Stroke Is Low in Children. Stroke 2020; 51:542-548. [DOI: 10.1161/strokeaha.119.027225] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Data regarding the safety and efficacy of intravenous tPA (tissue-type plasminogen activator) in childhood acute arterial ischemic stroke are inadequate. The TIPS trial (Thrombolysis in Pediatric Stroke; National Institutes of Health grant R01NS065848)—a prospective safety and dose-finding trial of intravenous tPA in acute childhood stroke—was closed for lack of accrual. TIPS sites have subsequently treated children with acute stroke in accordance with established institutional protocols supporting data collection on outcomes.
Methods—
Data on children treated with intravenous tPA for neuroimaging-confirmed arterial ischemic stroke were collected retrospectively from 16 former TIPS sites to establish preliminary safety data. Participating sites were required to report all children who were treated with intravenous tPA to minimize reporting bias. Symptomatic intracranial hemorrhage (SICH) was defined as ECASS (European Cooperative Acute Stroke Study) II parenchymal hematoma type 2 or any intracranial hemorrhage associated with neurological deterioration within 36 following tPA administration. A Bayesian beta-binomial model for risk of SICH following intravenous tPA was fit using a prior distribution based on the risk level in young adults (1.7%); to test for robustness, the model was also fit with uninformative and conservative priors.
Results—
Twenty-six children (age range, 1.1–17 years; median, 14 years; 12 boys) with stroke and a median pediatric National Institutes of Health Stroke Scale score of 14 were treated with intravenous tPA within 2 to 4.5 hours (median, 3.0 hours) after stroke onset. No patient had SICH. Two children developed epistaxis.
Conclusions—
The estimated risk of SICH after tPA in children is 2.1% (95% highest posterior density interval, 0.0%–6.7%; mode, 0.9%). Regardless of prior assumption, there is at least a 98% chance that the risk is <15% and at least a 93% chance that the risk is <10%. These results suggest that the overall risk of SICH after intravenous tPA in children with acute arterial ischemic stroke, when given within 4.5 hours after symptom onset, is low.
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Affiliation(s)
- Catherine Amlie-Lefond
- From the Department of Neurology (C.A.-L., M.S.W., J.L.-E), Seattle Children’s Hospital, WA
| | - Dennis W.W. Shaw
- Department of Radiology (D.W.W.S.), Seattle Children’s Hospital, WA
| | - Andrew Cooper
- Enterprise Analytics (A.C., D.B.), Seattle Children’s Hospital, WA
| | - Mark S. Wainwright
- From the Department of Neurology (C.A.-L., M.S.W., J.L.-E), Seattle Children’s Hospital, WA
| | - Adam Kirton
- Department of Neurology, Alberta Children’s Hospital, Calgary, Canada (A.K.)
| | - Ryan J. Felling
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD (R.J.F.)
| | | | - Mark T. Mackay
- Department of Neurology, The Royal Children’s Hospital, Melbourne, VIC, Australia (M.T.M.)
| | - Michael M. Dowling
- Department of Neurology, Children’s Medical Center at Dallas, TX (M.M.D.)
| | - Marcela Torres
- Department of Hematology, Cook Children’s Medical Center, Fort Worth, TX (M.T.)
| | | | - Eric F. Grabowski
- Department of Pediatric Hematology-Oncology, Massachusetts General Hospital, Boston (E.F.G.)
| | - Sarah Lee
- Department of Neurology, Stanford University, Palo Alto, CA (S.L.)
| | - Jonathan E. Kurz
- Department of Neurology, Ann & Robert H Lurie Children’s Hospital of Chicago, IL (J.E.K.)
| | - Hugh J. McMillan
- Department of Neurology, Children’s Hospital of Eastern Ontario, Ottawa, Canada (H.J.M.)
| | - Dwight Barry
- Enterprise Analytics (A.C., D.B.), Seattle Children’s Hospital, WA
| | - Jacqueline Lee-Eng
- From the Department of Neurology (C.A.-L., M.S.W., J.L.-E), Seattle Children’s Hospital, WA
| | - Rebecca N. Ichord
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (R.N.I.)
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48
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Derry PJ, Mandava P, Kent TA. Telemedicine in Prehospital Acute Stroke Care: An Expanding Infrastructure for Treatment and Research. J Am Heart Assoc 2020; 8:e012259. [PMID: 30879369 PMCID: PMC6475042 DOI: 10.1161/jaha.119.012259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
See Article by Geisler et al.
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Affiliation(s)
- Paul J Derry
- 1 Institute of Biosciences and Technology Texas A&M Health Science Center Houston TX
| | - Pitchaiah Mandava
- 2 Analytical Software and Engineering Research Laboratory Department of Neurology Baylor College of Medicine Michael E. DeBakey VA Medical Center Houston TX
| | - Thomas A Kent
- 1 Institute of Biosciences and Technology Texas A&M Health Science Center Houston TX.,3 Department of Neurology and Institute of Academic Medicine Houston Methodist Hospital Houston TX
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49
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Toyoda K, Koga M, Iguchi Y, Itabashi R, Inoue M, Okada Y, Ogasawara K, Tsujino A, Hasegawa Y, Hatano T, Yamagami H, Iwama T, Shiokawa Y, Terayama Y, Minematsu K. Guidelines for Intravenous Thrombolysis (Recombinant Tissue-type Plasminogen Activator), the Third Edition, March 2019: A Guideline from the Japan Stroke Society. Neurol Med Chir (Tokyo) 2019; 59:449-491. [PMID: 31801934 PMCID: PMC6923159 DOI: 10.2176/nmc.st.2019-0177] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine
| | | | - Manabu Inoue
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center
| | | | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital
| | | | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital
| | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine
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Liberman AL, Antoniello D, Tversky S, Fara MG, Zhang C, Gurin L, Rostanski SK. Multiple Administrations of Intravenous Thrombolytic Therapy to a Stroke Mimic. J Emerg Med 2019; 58:e133-e136. [PMID: 31806434 DOI: 10.1016/j.jemermed.2019.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/07/2019] [Accepted: 10/13/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients who present emergently with focal neurological deficits concerning for acute ischemic stroke can be extremely challenging to diagnose and treat. Unnecessary administration of thrombolytics to potential stroke patients whose symptoms are not caused by an acute ischemic stroke-stroke mimics-may result in patient harm, although the overall risk of hemorrhagic complications among stroke mimics is low. CASE REPORT We present a case of a stroke mimic patient with underlying psychiatric disease who was treated with intravenous alteplase on four separate occasions in four different emergency departments in the same city. Although he did not suffer hemorrhagic complications, this case highlights the importance of rapid exchange of health information across institutions to improve diagnostic quality and safety. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Increased awareness of stroke mimics by emergency physicians may improve diagnostic safety for a subset of high-risk patients. Establishing rapid cross-institutional communication pathways that are integrated into provider's workflows to convey essential patient health information has potential to improve stroke diagnostic decision-making and thus represents an important topic for health systems research in emergency medicine.
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Affiliation(s)
- Ava L Liberman
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Daniel Antoniello
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Steven Tversky
- Department of Neurology, Winthrop-University Hospital, Mineola, New York
| | - Michael G Fara
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cen Zhang
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Lindsey Gurin
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Sara K Rostanski
- Department of Neurology, New York University School of Medicine, New York, New York
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