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Farid HA, Naqvi A. The Burden of Stroke Mimics Among Hyperacute Stroke Unit Attendees with Special Emphasis on Migraine: A 10-Year Evaluation. Cureus 2024; 16:e59700. [PMID: 38840995 PMCID: PMC11151139 DOI: 10.7759/cureus.59700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Stroke and migraine are common neurological illnesses that cause tremendous suffering for patients. Certain diseases can mimic the clinical manifestations of an actual stroke. Migraine is one of the most commonly reported stroke mimics. The main goals of this study are to look at the prevalence of stroke mimics on the stroke pathway of Sheffield Teaching Hospitals and how many of them are migraines. MATERIALS AND METHODS A retrospective service evaluation was conducted at the hyperacute stroke unit (HASU) of the Royal Hallamshire Hospital (RHH) in the United Kingdom. The total admissions from 2013 to 2022 were collected from the Sentinel Stroke National Audit Programme database, and the number of stroke mimics was evaluated each year. The burden of migraine stroke mimics was also evaluated. Then, a one-year sample of stroke mimics was extracted to look for the types of each mimic. RESULTS From 2013 to 2022, 45.75% (n = 12156) of the stroke pathway patients (n = 26573) were stroke mimics, with an increment of up to 55% in the years 2021 and 2022. During these 10 years, migraine stroke mimics accounted for 10.21% of admissions (n = 1240). The three most common mimics in a one-year sample of stroke pathway patients were migraine (14.70%) (n = 373), functional neurological disorders (FNDs) (7.17%) (n = 182), and Guillain-Barré syndrome (6.66%) (n = 169). Seizures, syncope, and metabolic derangements were reported as mimics in 4.17% (n = 106), 3.14% (n = 80), and 1.77% (n = 45), respectively. CONCLUSIONS About half of the HASU attendees were stroke mimics rather than actual strokes, and the most common mimics were migraines.
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Affiliation(s)
- Hassan A Farid
- Neurology, St George's University of London, London, GBR
| | - Aaizza Naqvi
- Neurology, Sheffield Teaching Hospitals, Sheffield, GBR
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Alstadhaug KB, Tronvik E, Aamodt AH. Transient ischemic attack or migraine with aura? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2023; 143:23-0225. [PMID: 37874053 DOI: 10.4045/tidsskr.23.0225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023] Open
Abstract
Migraine or migraine-like symptoms can contribute to a delayed stroke diagnosis. However, migraine with aura is a common stroke mimic and often the basis for acute thrombolytic therapy. It is probably also the reason why many patients are misdiagnosed with a transient ischemic attack. In this clinical review, we explain the factors that could differentiate a transient ischemic attack from a migraine with aura.
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Alstadhaug KB, Aamodt AH. Etablering av medisinske sannheter. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2023; 143:23-0173. [PMID: 36987899 DOI: 10.4045/tidsskr.23.0173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
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Macias-Gómez A, Suárez-Pérez A, Rodríguez-Campello A, Giralt-Steinhauer E, Moreira A, Guisado-Alonso D, Capellades J, Fernández-Pérez I, Jiménez-Conde J, Rey L, Jiménez-Balado J, Roquer J, Ois Á, Cuadrado-Godia E. Factors associated with migraine aura mimicking stroke in code stroke. Neurol Sci 2023; 44:2113-2120. [PMID: 36749530 DOI: 10.1007/s10072-023-06641-y] [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: 11/09/2022] [Accepted: 01/23/2023] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Migraine with aura (MA) is a frequent stroke simulator that can lead to erroneous diagnosis and subsequent unnecessary acute or secondary prevention treatments. We analyzed clinical and laboratory data of migraine with aura and ischemic stroke patients to detect differences that could help in the diagnosis. METHODS Retrospective analysis of a consecutive register of code strokes between January 2005 and June 2020. Diagnosis of ischemic stroke or MA was collected. Multivariable logistic regression analyses were performed to test associations between clinical and blood data with ischemic stroke. RESULTS Of 3140 code strokes, 2424 (77.2%) were ischemic strokes and 34 (1.1%) were MA. Migraine cases were younger, more frequently females and with lower prevalence of vascular risk factors. Initial NIHSS was lower in MA cases, but no differences were seen in fibrinolysis rate (30%). Blood test showed lower levels of glucose, D-dimer, and fibrinogen in MA cases. Multivariable model showed and independent association for ischemic stroke with age [OR, (95%CI): 1.09, (1.07-1.12, p < 0.001], male sex [OR, (95%CI): 4.47, (3.80-5.13), p < 0.001], initial NIHSS [OR, (95%CI): 1.21, (1.07-1.34), p < 0.01], and fibrinogen levels [OR, (95%CI): 1.01, (1.00-1.01), p < 0.05]. A model including sex male OR: 3.55 [2.882; 4.598], p < 0.001, and cutoff points (age > 65, OR: 7.953 [7.256; 8.649], p < 0.001, NIHSS > 6, OR: 3.740 [2.882; 4.598], p < 0.01, and fibrinogen > 400 mg/dL, OR: 2.988 [2.290; 3.686], p < 0.01) showed a good global discrimination capability AUC = 0.89 (95%CI: 0.88-0.94). CONCLUSIONS In code stroke, a model including age, sex, NIHSS, and fibrinogen showed a good discrimination capability to differentiate between MA and Ischemic stroke. Whether these variables can be implemented in a diagnostic rule should be tested in future studies.
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Affiliation(s)
- Adrià Macias-Gómez
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Antoni Suárez-Pérez
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Ana Rodríguez-Campello
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Eva Giralt-Steinhauer
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain. .,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain.
| | - Antía Moreira
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain
| | - Daniel Guisado-Alonso
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain
| | - Jaume Capellades
- Neuroradiology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain
| | - Isabel Fernández-Pérez
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Jordi Jiménez-Conde
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Lucía Rey
- Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Joan Jiménez-Balado
- Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Jaume Roquer
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Ángel Ois
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
| | - Elisa Cuadrado-Godia
- Neurology Department, Hospital del Mar, Passeig Marítim de la Barceloneta 25-29, 08003, Barcelona, Spain.,Neurovascular Research Group, IMIM-Hospital del Mar Medical Research Institute, Carrer del Dr. Aiguader, 88, 08003, Barcelona, Spain
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Altamura C, Viticchi G, Rizzo AC, Maggio P, Brunelli N, Marcosano M, Lazzaro VD, Fiacco F, Agostoni EC, Silvestrini M, Vernieri F. Stroke territory and atherosclerosis in ischemic stroke patients with a history of migraine with aura. Front Neurol 2023; 14:1142424. [PMID: 36923493 PMCID: PMC10008946 DOI: 10.3389/fneur.2023.1142424] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/02/2023] [Indexed: 03/01/2023] Open
Abstract
Introduction The mechanisms subtending the increased stroke risk in migraine with aura (MA) are not fully understood. Our study aims to evaluate if the clinical profile in stroke patients with MA differentiates from those without MA. Methods We retrieved the prospective registered electronic clinical dossiers of adult patients younger than 60 years with acute ischemic stroke admitted in four hospitals between January 2016 and June 2022. Patients were classified by the history of MA (MA+ and MA-). Results We identified 851 stroke patients (59 MA+, 6.9%). Compared to MA-, MA+ patients were characterized by younger age (44.0 ± 10.6 vs 50.1 ± 8.2 years), female sex (59.3% vs 29.0%), and affected by cryptogenic (OR 2.594 95% CI 1.483-4.537), and cerebellar stroke (OR 3.218 95% CI 1.657-6.250; p ≤ 0.001 for all comparisons). After adjusting for age and sex, MA+ patients presented less frequently hypertension (OR 0.349 95% CI 0.167-0.470; p=0.005) and dyslipidemia (OR 0.523 95% CI 0.280-0.974; p = 0.041). After adjusting also for risk factors, the MA+ group had less frequently symptomatic large vessel stenosis (OR 0.126 95% CI 0.017-0,924; p = 0.042) and clinical atherosclerosis (OR 0.103 95% CI 0.014-0.761; p = 0.026), while intima-media thickness did not differ (p = 0.395). Discussion Cryptogenic and cerebellar stroke and fewer vascular risk factors and clinical atherosclerosis seem to characterize stroke patients with MA.
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Affiliation(s)
- Claudia Altamura
- Department of Medicine and Surgery, Unit of Headache and Neurosonology, Università Campus Bio-Medico di Roma, Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- *Correspondence: Claudia Altamura ✉
| | | | - Angelo Cascio Rizzo
- Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Paola Maggio
- Neurology Unit, ASST Bergamo Est, Seriate, Italy
| | - Nicoletta Brunelli
- Department of Medicine and Surgery, Unit of Headache and Neurosonology, Università Campus Bio-Medico di Roma, Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Marilena Marcosano
- Department of Medicine and Surgery, Unit of Headache and Neurosonology, Università Campus Bio-Medico di Roma, Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Vincenzo Di Lazzaro
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology, and Psychiatry, Università Campus Bio-Medico di Roma, Roma, Italy
| | | | | | | | - Fabrizio Vernieri
- Department of Medicine and Surgery, Unit of Headache and Neurosonology, Università Campus Bio-Medico di Roma, Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
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Strambo D, Nannoni S, Rebordão L, Dunet V, Michel P. Computed tomographic perfusion abnormalities in acute migraine with aura: Characteristics and comparison with transient ischemic attack. Eur Stroke J 2022; 7:431-438. [PMID: 36478764 PMCID: PMC9720859 DOI: 10.1177/23969873221114256] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 10/25/2023] Open
Abstract
INTRODUCTION Migraine with aura (MA) accounts for up to 10% of "stroke mimics" and can present cerebral perfusion abnormalities. We aimed to compare perfusion-CT (PCT) findings in acute-onset MA mimicking an ischemic stroke with those observed in transient ischemic attack (TIA). METHODS We retrospectively studied patients admitted to our hospital between 2002 and 2014 with suspicion of acute ischemic stroke, having PCT and receiving a final diagnosis of MA. We visually assessed PCT for the presence and extent of focal hypoperfusion (FHP). MA patients with FHP were compared with consecutive TIA patients showing FHP. We performed both qualitative and quantitative analysis of PCT. RESULTS Of 47 patients with MA (median age = 33 years, 55% females), 16 (34%) displayed FHP. Compared to MA patients without FHP, MA patients with FHP had similar headaches and aura features, but a less frequent history of MA (p = 0.010). Compared to 74 TIA patients with FHP (median age = 69 years, 43% females), MA patients with FHP showed hypoperfusion that more frequently involved adjacent vascular territories or a whole hemisphere (p < 0.001). In addition, hypoperfusion in MA patients had a less pronounced increase in rMTT (1.2 vs 1.8, p < 0.001) and rTTP (1.1 vs 1.2, p < 0.001), and a lesser decrease in rCBF (0.8 vs 0.6, p < 0.001) compared to hypoperfusion in TIA. rMTT displayed the best discriminative ability to differentiate MA from TIA. CONCLUSION Focal perfusion abnormalities in acute MA often involve adjacent vascular territories and hypoperfusion is less pronounced than in TIA. MA can be best differentiated from TIA by a smaller rMTT increase.
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Affiliation(s)
- Davide Strambo
- Stroke Center, Neurology Service,
Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Stefania Nannoni
- Stroke Center, Neurology Service,
Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Leonor Rebordão
- Department of Neurology, Hospital
Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Vincent Dunet
- Department of Diagnostic and
Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service,
Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Southey CC, Birns J, Sommerville P, Bhalla A. Transient unilateral weakness: is it a transient ischaemic attack? Br J Hosp Med (Lond) 2022; 83:1-7. [DOI: 10.12968/hmed.2022.0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transient ischaemic attack is an emergency medical condition that causes brief negative focal neurological symptoms such as unilateral weakness. The symptoms herald a high risk of stroke and hence require urgent assessment. The challenge lies in the brevity and compendium of associated symptoms that can ‘mimic’ a plethora of other conditions. The result is a high rate of referrals to transient ischaemic attack clinics for these stroke mimics. This article highlights the diagnostic challenges in transient ischaemic attack with relevance to unilateral weakness.
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Affiliation(s)
- Charles C Southey
- Department of Ageing and Health, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Jonathan Birns
- Department of Ageing and Health, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Peter Sommerville
- Department of Ageing and Health, Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | - Ajay Bhalla
- Department of Ageing and Health, Guy's and St Thomas’ NHS Foundation Trust, London, UK
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8
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Dahl FA, Barra M, Faiz KW, Ihle-Hansen H, Næss H, Rand K, Rønning OM, Simonsen TB, Thommessen B, Labberton AS. Stroke unit demand in Norway - present and future estimates. BMC Health Serv Res 2022; 22:336. [PMID: 35287661 PMCID: PMC8922921 DOI: 10.1186/s12913-021-07385-1] [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: 07/19/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND All stroke patients should receive timely admission to a stroke unit (SU). Consequently, most patients with suspected strokes - including stroke mimics (SM) are admitted. The aim of this study was to estimate the current total demand for SU bed capacity today and give estimates for future (2020-2040) demand. METHODS Time trend estimates for stroke incidence and time constant estimates for length of stay (LOS) were estimated from the Norwegian Patient Registry (2010-2015). Incidence and LOS models for SMs were based on data from Haukeland University Hospital (2008-2017) and Akershus University Hospital (2020), respectively. The incidence and LOS models were combined with scenarios from Statistic Norway's population predictions to estimate SU demands for each health region. A telephone survey collected data on the number of currently available SU beds. RESULTS In 2020, 361 SU beds are available, while demand was estimated to 302. The models predict a reduction in stroke incidence, which offsets projected demographic shifts. Still, the estimated demand for 2040 rose to 316, due to an increase in SMs. A variation of this reference scenario, where stroke incidence was frozen at the 2020-level, gave a 2040-demand of 480 beds. CONCLUSIONS While the stroke incidence is likely to continue to fall, this appears to be balanced by an increase in SMs. An important uncertainty is how long the trend of decreasing stroke incidence can be expected to continue. Since the most important uncertainty factors point toward a potential increase, which may be as large as 50%, we would recommend that the health authorities plan for a potential increase in the demand for SU bed capacity.
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Affiliation(s)
- Fredrik A Dahl
- The Health Services Research Unit (HØKH), Akershus University Hospital HF, Sykehusveien 25, 1478, Lørenskog, Norway.,Norwegian Computing Center, Oslo, Norway
| | - Mathias Barra
- The Health Services Research Unit (HØKH), Akershus University Hospital HF, Sykehusveien 25, 1478, Lørenskog, Norway. .,BCEPS, University of Bergen, Bergen, Norway. .,Centre for Connected Care, Oslo University Hospital, Oslo, Norway.
| | - Kashif W Faiz
- The Health Services Research Unit (HØKH), Akershus University Hospital HF, Sykehusveien 25, 1478, Lørenskog, Norway
| | - Hege Ihle-Hansen
- Department of Geriatric Medicine, OUS, Oslo, Norway.,Department of Neurology, OUS, Oslo, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Centre for Age-related Medicine, Stavanger University Hospital, Stavanger, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kim Rand
- The Health Services Research Unit (HØKH), Akershus University Hospital HF, Sykehusveien 25, 1478, Lørenskog, Norway
| | - Ole Morten Rønning
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Tone Breines Simonsen
- The Health Services Research Unit (HØKH), Akershus University Hospital HF, Sykehusveien 25, 1478, Lørenskog, Norway.,Centre for Connected Care, Oslo University Hospital, Oslo, Norway
| | - Bente Thommessen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Angela S Labberton
- The Health Services Research Unit (HØKH), Akershus University Hospital HF, Sykehusveien 25, 1478, Lørenskog, Norway.,Norwegian Institute of Public Health, Health Services Research, Oslo, Norway
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9
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Collins-Yoder A, Key B. Acute ischemic stroke or migraine with aura? Triage considerations. Nursing 2022; 52:17-23. [PMID: 35085190 DOI: 10.1097/01.nurse.0000806152.65968.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT This article discusses the complex relationship between acute ischemic stroke and migraine with aura, and critical nursing interventions.
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Affiliation(s)
- Angela Collins-Yoder
- Angela Collins-Yoder is a clinical professor at the University of Alabama's Capstone College of Nursing and a critical care clinical nurse specialist at Ascension Sacred Heart. Betty Key is an assistant professor at Samford University in Birmingham, Ala
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Ali M, van Os HJA, van der Weerd N, Schoones JW, Heymans MW, Kruyt ND, Visser MC, Wermer MJH. Sex Differences in Presentation of Stroke: A Systematic Review and Meta-Analysis. Stroke 2021; 53:345-354. [PMID: 34903037 PMCID: PMC8785516 DOI: 10.1161/strokeaha.120.034040] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND PURPOSE Women have worse outcomes than men after stroke. Differences in presentation may lead to misdiagnosis and, in part, explain these disparities. We investigated whether there are sex differences in clinical presentation of acute stroke or transient ischemic attack. METHODS We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Inclusion criteria were (1) cohort, cross-sectional, case-control, or randomized controlled trial design; (2) admission for (suspicion of) ischemic or hemorrhagic stroke or transient ischemic attack; and (3) comparisons possible between sexes in ≥1 nonfocal or focal acute stroke symptom(s). A random-effects model was used for our analyses. We performed sensitivity and subanalyses to help explain heterogeneity and used the Newcastle-Ottawa Scale to assess bias. RESULTS We included 60 studies (n=582 844; 50% women). In women, headache (pooled odds ratio [OR], 1.24 [95% CI, 1.11-1.39]; I2=75.2%; 30 studies) occurred more frequently than in men with any type of stroke, as well as changes in consciousness/mental status (OR, 1.38 [95% CI, 1.19-1.61]; I2=95.0%; 17 studies) and coma/stupor (OR, 1.39 [95% CI, 1.25-1.55]; I2=27.0%; 13 studies). Aspecific or other neurological symptoms (nonrotatory dizziness and non-neurological symptoms) occurred less frequently in women (OR, 0.96 [95% CI, 0.94-0.97]; I2=0.1%; 5 studies). Overall, the presence of focal symptoms was not associated with sex (pooled OR, 1.03) although dysarthria (OR, 1.14 [95% CI, 1.04-1.24]; I2=48.6%; 11 studies) and vertigo (OR, 1.23 [95% CI, 1.13-1.34]; I2=44.0%; 8 studies) occurred more frequently, whereas symptoms of paresis/hemiparesis (OR, 0.73 [95% CI, 0.54-0.97]; I2=72.6%; 7 studies) and focal visual disturbances (OR, 0.83 [95% CI, 0.70-0.99]; I2=62.8%; 16 studies) occurred less frequently in women compared with men with any type of stroke. Most studies contained possible sources of bias. CONCLUSIONS There may be substantive differences in nonfocal and focal stroke symptoms between men and women presenting with acute stroke or transient ischemic attack, but sufficiently high-quality studies are lacking. More studies are needed to address this because sex differences in presentation may lead to misdiagnosis and undertreatment.
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Affiliation(s)
- Mariam Ali
- Department of Neurology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands (M.A., M.C.V.)
| | - Hendrikus J A van Os
- Department of Neurology, Leiden University Medical Center, the Netherlands. (H.J.A.v.O., N.v.d.W., N.D.K., M.J.H.W.)
| | - Nelleke van der Weerd
- Department of Neurology, Leiden University Medical Center, the Netherlands. (H.J.A.v.O., N.v.d.W., N.D.K., M.J.H.W.)
| | - Jan W Schoones
- Walaeus Library, Leiden University Medical Center, the Netherlands. (J.W.S.)
| | - Martijn W Heymans
- Department of Clinical Epidemiology and Biostatistics, Amsterdam UMC, the Netherlands (M.W.H.)
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, the Netherlands. (H.J.A.v.O., N.v.d.W., N.D.K., M.J.H.W.)
| | - Marieke C Visser
- Department of Neurology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands (M.A., M.C.V.)
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, the Netherlands. (H.J.A.v.O., N.v.d.W., N.D.K., M.J.H.W.)
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11
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Gonzalez-Martinez A, Trillo Senín S, Benavides Bernaldo de Queirós C, Casado Fernández L, Barbosa Del Olmo A, Manzanares López R, Gago-Veiga AB, Vivancos J. Clinical characteristics and perfusion-computed tomography alterations in a series of patients with migraine with aura attended as stroke code. Headache 2021; 61:1568-1574. [PMID: 34862603 DOI: 10.1111/head.14243] [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: 12/19/2020] [Revised: 08/21/2021] [Accepted: 09/20/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of the current study was to determine the clinical characteristics of migraine with aura (MA) as well as the frequency and patterns of perfusion-computed tomography (PCT) alterations, in a series of patients with MA mimicking acute ischemic stroke. BACKGROUND MA is one of the most frequent stroke mimics, following seizures and psychiatric disorders. Previous case reports and short series have reported abnormal PCT patterns in patients with MA. METHODS We conducted a retrospective cohort study including all consecutive patients presenting with focal neurological symptoms during complete multimodal CT including baseline CT, angio-CT, and PCT with a final diagnosis of MA. We collected demographic data and clinical information about MA variables using the hospital electronic database. RESULTS We found 25 patients with a final diagnosis of MA among 1761 patients who attended our stroke center with complete multimodal CT (1.4% [95% CI: 0.9-2.1]). Among them, 14/25 (56%) were women, average age 38.7 years (SD 12.5), and 16/25 (64%) had a previous history of migraine. The most frequent type of aura was sensory. The median time elapsed between the onset of symptoms and CT was 171 min (IQR: 119-244). PCT alteration was found in 3/25 (12%) consisting of a hypoperfusion pattern not restricted to a vascular territory. The three patients had aphasia as the presenting symptom. CONCLUSION This is, to the best of our knowledge, the largest series of patients with MA managed as presumed stroke with clinical characteristics and PCT. In our study, most patients were young and had a prior history of migraine. PCT was normal in 88% of cases, with patients being still symptomatic by the time they were scanned. Further research will clarify the presence and type of PCT alterations in this entity.
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Affiliation(s)
- Alicia Gonzalez-Martinez
- Department of Neurology, Hospital Universitario de La Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Santiago Trillo Senín
- Stroke Unit, Department of Neurology, Hospital Universitario de La Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | | | - Laura Casado Fernández
- Department of Neurology, Hospital Universitario de La Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Antonio Barbosa Del Olmo
- Department of Neuroradiology, Hospital Universitario de La Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Rafael Manzanares López
- Department of Neuroradiology, Hospital Universitario de La Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - Ana Beatriz Gago-Veiga
- Headache Unit, Department of Neurology, Hospital Universitario de La Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | - José Vivancos
- Stroke Unit, Department of Neurology, Hospital Universitario de La Princesa & Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
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12
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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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13
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Sumelahti ML, Sumanen MS, Mattila KJ, Sillanmäki L, Sumanen M. Stroke and cardiovascular risk factors among working-aged Finnish migraineurs. BMC Public Health 2021; 21:1088. [PMID: 34098909 PMCID: PMC8186106 DOI: 10.1186/s12889-021-11006-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/07/2021] [Indexed: 11/17/2022] Open
Abstract
Background The aim of our study was to evaluate the risk for comorbid cardio- and cerebrovascular diseases in the working-aged migraine population of Finland. Methods A total of 1505 cases who reported diagnosed migraine and 3010 controls from a cohort of 11,596 cases in the Finnish Health and Social Support Study were included. The study material was linked with two registers. ICD diagnoses I63 for ischemic stroke (IS), I21 − I22 for acute myocardial infarction (AMI), and G43 for transient ischemic attack (TIA) among study participants were drawn from the national Finnish Care Register for Health Care at the follow-up in 2012. Reimbursed triptan prescriptions were drawn from the national Social Security Institution (SII) data. The self-reported vascular risk factors were hypertension, high cholesterol values, any diabetes, myocardial infarction, stroke, and TIA. Odds Ratios (OR) with 95% confidence (95% CI) intervals were assessed for diagnosed stroke, myocardial infarction, and TIA. Results Migraineurs were mostly female (82%) and ≥ 54 years old (62%). Triptans were reimbursed among 34.7% of migraineurs. A self-reported hypertension (21%), high serum cholesterol (38%), and any diabetes (7%) were more common among migraineurs vs controls (p < 0.05). There was no risk for AMI. The risk for TIA (OR 3.20, 95% CI 1.45–7.05) and IS (2.57, 95% CI 1.28–5.17) among migraineurs vs controls remained high after adjustment for self-reported hypertension, obesity, and smoking. The risk was higher among women in two groups ≥54 years (3.25, 95% CI 1.35–7.84 and 5.0, 95% CI 1.94–12.89, respectively). The average age for IS in migraine was 57.5 years and for TIA 58.2 years among women, and 52.8 years and 50.3 years among men, respectively. Conclusion Cardiovascular risk should be screened in the aging migraine population, and hormonal and other migraine-related risk factors should be considered, especially among women. Efficacious attack treatment with triptans should be offered to migraine patients who do not show contraindications.
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Affiliation(s)
- Marja-Liisa Sumelahti
- Faculty of Medicine and Health Technology, Tampere University, 33014, Tampere, Finland.
| | - Merika S Sumanen
- Faculty of Medicine and Health Technology, Tampere University, 33014, Tampere, Finland
| | - Kari J Mattila
- Faculty of Medicine and Health Technology, Tampere University, 33014, Tampere, Finland
| | - Lauri Sillanmäki
- Department of Public Health, Turku University Hospital, Turku, Finland
| | - Markku Sumanen
- Faculty of Medicine and Health Technology, Tampere University, 33014, Tampere, Finland
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14
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Abstract
Migraine with aura is one of the causes of stroke mimics. We retrospectively reviewed the 10-year medical records of patients who were treated with acute stroke management protocol. We analyzed the frequency and characteristics of patients with a final diagnosis of migraine with aura. Among the 1355 patients with stroke mimics, migraine with aura was the final diagnosis in 36 patients (2.7%). The most common auras included sensory and brainstem auras followed by motor, visual, and speech/language auras. One patient manifested transient atrial fibrillation during the migraine attack, which can be a link with acute stroke.
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15
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Altamura C, Corbelli I, de Tommaso M, Di Lorenzo C, Di Lorenzo G, Di Renzo A, Filippi M, Jannini TB, Messina R, Parisi P, Parisi V, Pierelli F, Rainero I, Raucci U, Rubino E, Sarchielli P, Li L, Vernieri F, Vollono C, Coppola G. Pathophysiological Bases of Comorbidity in Migraine. Front Hum Neurosci 2021; 15:640574. [PMID: 33958992 PMCID: PMC8093831 DOI: 10.3389/fnhum.2021.640574] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/23/2021] [Indexed: 12/12/2022] Open
Abstract
Despite that it is commonly accepted that migraine is a disorder of the nervous system with a prominent genetic basis, it is comorbid with a plethora of medical conditions. Several studies have found bidirectional comorbidity between migraine and different disorders including neurological, psychiatric, cardio- and cerebrovascular, gastrointestinal, metaboloendocrine, and immunological conditions. Each of these has its own genetic load and shares some common characteristics with migraine. The bidirectional mechanisms that are likely to underlie this extensive comorbidity between migraine and other diseases are manifold. Comorbid pathologies can induce and promote thalamocortical network dysexcitability, multi-organ transient or persistent pro-inflammatory state, and disproportionate energetic needs in a variable combination, which in turn may be causative mechanisms of the activation of an ample defensive system with includes the trigeminovascular system in conjunction with the neuroendocrine hypothalamic system. This strategy is designed to maintain brain homeostasis by regulating homeostatic needs, such as normal subcortico-cortical excitability, energy balance, osmoregulation, and emotional response. In this light, the treatment of migraine should always involves a multidisciplinary approach, aimed at identifying and, if necessary, eliminating possible risk and comorbidity factors.
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Affiliation(s)
- Claudia Altamura
- Headache and Neurosonology Unit, Neurology, Campus Bio-Medico University Hospital, Rome, Italy
| | - Ilenia Corbelli
- Clinica Neurologica, Dipartimento di Medicina, Ospedale S.M. Misericordia, Università degli Studi di Perugia, Perugia, Italy
| | - Marina de Tommaso
- Applied Neurophysiology and Pain Unit, SMBNOS Department, Bari Aldo Moro University, Policlinico General Hospital, Bari, Italy
| | - Cherubino Di Lorenzo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
| | - Giorgio Di Lorenzo
- Laboratory of Psychophysiology and Cognitive Neuroscience, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,IRCCS-Fondazione Santa Lucia, Rome, Italy
| | | | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, Institute of Experimental Neurology, Milan, Italy.,Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Tommaso B Jannini
- Laboratory of Psychophysiology and Cognitive Neuroscience, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Roberta Messina
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Pasquale Parisi
- Child Neurology, Department of Neuroscience, Mental Health and Sense Organs (NESMOS), Faculty of Medicine & Psychology, c/o Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | | | - Francesco Pierelli
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy.,Headache Clinic, IRCCS-Neuromed, Pozzilli, Italy
| | - Innocenzo Rainero
- Neurology I, Department of Neuroscience "Rita Levi Montalcini," University of Torino, Torino, Italy
| | - Umberto Raucci
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS), Rome, Italy
| | - Elisa Rubino
- Neurology I, Department of Neuroscience "Rita Levi Montalcini," University of Torino, Torino, Italy
| | - Paola Sarchielli
- Clinica Neurologica, Dipartimento di Medicina, Ospedale S.M. Misericordia, Università degli Studi di Perugia, Perugia, Italy
| | - Linxin Li
- Nuffield Department of Clinical Neurosciences, Centre for Prevention of Stroke and Dementia, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Fabrizio Vernieri
- Headache and Neurosonology Unit, Neurology, Campus Bio-Medico University Hospital, Rome, Italy
| | - Catello Vollono
- Department of Neurology, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Catholic University, Rome, Italy
| | - Gianluca Coppola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino, Latina, Italy
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16
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Poupore N, Strat D, Mackey T, Snell A, Nathaniel T. Ischemic stroke with a preceding Trans ischemic attack (TIA) less than 24 hours and thrombolytic therapy. BMC Neurol 2020; 20:197. [PMID: 32429850 PMCID: PMC7236928 DOI: 10.1186/s12883-020-01782-5] [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] [Received: 10/24/2019] [Accepted: 05/13/2020] [Indexed: 12/02/2022] Open
Abstract
Background Acute ischemic stroke attack with and without a recent TIA may differ in clinical risk factors, and this may affect treatment outcomes following thrombolytic therapy. We examined whether the odds of exclusion or inclusion for thrombolytic therapy are greater in ischemic stroke with TIA less than 24 h preceding ischemic stroke (recent-TIA) as compared to those without recent TIA or non-TIA > 24 h and less than 1 month (past-TIA). Methods A retrospective hospital-based analysis was conducted on 6315 ischemic stroke patients, of whom 846 had proven brain diffusion-weighted magnetic resonance imaging (DW-MRI) of an antecedent TIA within 24 h prior to ischemic stroke. The logistic regression model was developed to generate odds ratios (OR) to determine clinical factors that may increase the likelihood of exclusion or inclusion for thrombolytic therapy. The validity of the model was tested using a Hosmer-Lemeshow test, while the Receiver Operating Curve (ROC) was used to test the sensitivity of our model. Results In the recent-TIA ischemic stroke population, patients with a history of alcohol abuse (OR = 5.525, 95% CI, 1.003–30.434, p = 0.05), migraine (OR = 4.277, 95% CI, 1.095–16.703, p = 0.037), and increasing NIHSS score (OR = 1.156, 95% CI, 1.058–1.263, p = 0.001) were associated with the increasing odds of receiving rtPA, while older patients (OR = 0.965, 95% CI, 0.934–0.997, P = 0.033) were associated with the increasing odds of not receiving rtPA. Conclusion In recent-TIA ischemic stroke patients, older patients with higher INR values are associated with increasing odds of exclusion from thrombolytic therapy. Our findings demonstrate clinical risks factors that can be targeted to improve the use and eligibility for rtPA in in recent-TIA ischemic stroke patients.
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17
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Gökçen E, Hamamcı M. Ultrasonographic measurement of the optic nerve sheath in the differential diagnosis and follow-up of migraine with and without aura: A pilot study. Clin Neurol Neurosurg 2020; 198:106191. [PMID: 32937274 DOI: 10.1016/j.clineuro.2020.106191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/21/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Headache continues to be a common cause of emergency admissions. At first glance, primary headaches may not be distinguished from secondary headaches. This study aimed to evaluate the use of ultrasonic measurement of optic nerve sheath diameter (ONSD) in the clinical diagnosis of migraine patients during attack and during periods without attacks. PATIENTS AND METHODS This prospective study was conducted at the emergency department and neurology outpatient clinic of a tertiary hospital between October 2019 and January 2020. Patients diagnosed with episodic migraine and between ages 18-60 were included in the study. Migraine diagnosis and classification were based on criteria from the 2018 International Classification of Headache Disorders. ONSD measurement was performed with ultrasonography. ONSD measurements of the same migraine patients during attack and attack-free periods were compared with measurements of healthy volunteers. RESULTS A total of 82 participants consisting of 42 migraine patients and 40 control subjects were evaluated. In the control group, mean ONSD of the right eye was 4.88 ± 0.31 mm and mean ONSD of the left eye was 4.86 ± 0.31 mm. Mean ONSD measurement of the left eye was 4.80 ± 0.36 mm and mean ONSD of the right eye was 4.82 ± 0.37 during the attack period of the migraine patients. There was no significant difference between the migraine patients and the control group according to right and left eye ONSD measurements (attack-free period: p = 0.200, p = 0.448; attack period: p = 0.338, p = 0.660, respectively). There was no significant difference between ONSD measurements during the attack period and attack-free period in migraine patients (right eye p = 0.32; left eye p = 0.532). CONCLUSION The results of our study indicate that ONSD measurements may provide clinical insight into differential diagnosis preceding neuroimaging in migraine patients. On the other hand, since our study is the first on this topic, it should be noted that further studies are needed to come to a conclusion.
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Affiliation(s)
- Emre Gökçen
- Department of Emergency Medicine, Bozok University Faculty of Medicine, Yozgat, Turkey.
| | - Mehmet Hamamcı
- Department of Neurology, Bozok University Faculty of Medicine, Yozgat, Turkey.
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18
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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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19
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Di Stefano V, Rispoli MG, Pellegrino N, Graziosi A, Rotondo E, Napoli C, Pietrobon D, Brighina F, Parisi P. Diagnostic and therapeutic aspects of hemiplegic migraine. J Neurol Neurosurg Psychiatry 2020; 91:764-771. [PMID: 32430436 PMCID: PMC7361005 DOI: 10.1136/jnnp-2020-322850] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 01/25/2023]
Abstract
Hemiplegic migraine (HM) is a clinically and genetically heterogeneous condition with attacks of headache and motor weakness which may be associated with impaired consciousness, cerebellar ataxia and intellectual disability. Motor symptoms usually last <72 hours and are associated with visual or sensory manifestations, speech impairment or brainstem aura. HM can occur as a sporadic HM or familiar HM with an autosomal dominant mode of inheritance. Mutations in CACNA1A, ATP1A2 and SCN1A encoding proteins involved in ion transport are implicated. The pathophysiology of HM is close to the process of typical migraine with aura, but appearing with a lower threshold and more severity. We reviewed epidemiology, clinical presentation, diagnostic assessment, differential diagnosis and treatment of HM to offer the best evidence of this rare condition. The differential diagnosis of HM is broad, including other types of migraine and any condition that can cause transitory neurological signs and symptoms. Neuroimaging, cerebrospinal fluid analysis and electroencephalography are useful, but the diagnosis is clinical with a genetic confirmation. The management relies on the control of triggering factors and even hospitalisation in case of long-lasting auras. As HM is a rare condition, there are no randomised controlled trials, but the evidence for the treatment comes from small studies.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, Palermo, Sicilia, Italy
| | - Marianna Gabriella Rispoli
- Department of Neuroscience Imaging and Clinical Sciences, 'G. d'Annunzio' University, Universita degli Studi Gabriele d'Annunzio Chieti e Pescara, Chieti Scalo, Chieti, Italy
| | - Noemi Pellegrino
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Alessandro Graziosi
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Eleonora Rotondo
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Christian Napoli
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Roma, Lazio, Italy
| | - Daniela Pietrobon
- Department of Biomedical Sciences & Padova Neuroscience Center, University of Padova, Padova, Italy.,CNR Neuroscience Institute, Padova, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, Palermo, Sicilia, Italy
| | - Pasquale Parisi
- Dipartimento di Neuroscienze Salute Mentale e Organi di Senso (NESMOS), University of Rome La Sapienza Faculty of Medicine and Psychology, Roma, Lazio, Italy
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20
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A novel computed tomography perfusion-based quantitative tool for evaluation of perfusional abnormalities in migrainous aura stroke mimic. Neurol Sci 2020; 41:3321-3328. [PMID: 32458253 DOI: 10.1007/s10072-020-04476-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 05/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Migrainous aura (MA) represents the third most common stroke mimic (SM). Advanced neuroimaging is pivotal in the assessment of patients with focal neurological acute symptoms. We investigated brain perfusion alterations in MA-SM patients using a novel CT perfusion (CTP)-based quantitative approach in order to improve differential diagnosis between MA and acute stroke. METHODS We processed and analysed the clinical and neuroimaging CTP data, acquired within 4.5 h from symptom onset, of patients with acute focal neurological symptoms receiving a final diagnosis of MA. The differences between ROI, compatible with MA symptoms, and contralateral side were automatically estimated in terms of asymmetry index (AI%) by the newly developed tool for mean transit time (MTT), CBF, and cerebral blood volume (CBV) CTP parameters. The AI% ≥ 10% was considered significant. RESULTS Out of 923 admitted patients, 14 patients with MA were included. In 13 out of 14 cases, a significant pattern of hypoperfusion was observed by quantitative analysis in at least one of the CTP maps. In 7 patients, all three CTP maps were significantly altered. In particular, MTT-AI% increased in 11 (79%) cases, while CBF-AI% and CBV-AI% decreased in 12 (86%) and in 9 (64%) patients, respectively. All CBV values were above ischemic stroke core threshold and all MTT-AI were below ischemic penumbra threshold. CONCLUSIONS Our data suggest that a novel CTP-quantitative approach may detect during MA a moderate hypoperfusion pattern in the cerebral regions compatible with aura symptoms. The use of this novel tool could support differential diagnosis between MA and acute stroke.
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22
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Sipilä JO, Ruuskanen JO, Rautava P, Kytö V. Adult Migraine Hospital Admission Trends in Finland: A Nationwide Registry Study. J Clin Med 2020; 9:jcm9020320. [PMID: 31979328 PMCID: PMC7073942 DOI: 10.3390/jcm9020320] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/13/2020] [Accepted: 01/21/2020] [Indexed: 01/26/2023] Open
Abstract
Abstract:Population-level data on migraine hospital admission trends are unavailable. Changes in stroke care may have influenced these, since migraine is one of the most common stroke mimics. In this study, all hospital admissions on neurological, internal medicine, and pediatric wards in Finland with migraine as the primary diagnosis for persons at least 16 years of age in 2004-2014 were studied, resulting in an analysis of 6195 individuals with 7764 migraine discharges. The number of discharges increased by 4.2% annually (p = 0.000084), with no change in age of the admitted patients. Comorbidity burden was low but increased during the study period (p < 0.0001). The frequency of common vascular risk factors as comorbidities increased by 11-19% annually. Admission duration shortened by 2% annually (p < 0.0001). An intravenous thrombolysis was given in four admissions. It seems that migraine hospital admissions have become more frequent and the patients more often have cardiovascular risk factors, suggesting increased awareness and more aggressive acute evaluation of suspected stroke as the cause.
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Affiliation(s)
- Jussi O.T. Sipilä
- Siun sote, North Karelia Central Hospital, Department of Neurology, 80210 Joensuu, Finland
- Division of Clinical Neurosciences, Department of Neurology, Turku University Hospital, 20521 Turku, Finland;
- Clinical Neurosciences, University of Turku, 20520 Turku, Finland
- Correspondence:
| | - Jori O. Ruuskanen
- Division of Clinical Neurosciences, Department of Neurology, Turku University Hospital, 20521 Turku, Finland;
- Clinical Neurosciences, University of Turku, 20520 Turku, Finland
| | - Päivi Rautava
- Department of Public Health, University of Turku, 20520 Turku, Finland;
- Turku Clinical Research Centre, Turku University Hospital, 20521 Turku, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital, 20521 Turku, Finland;
- Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, 20520 Turku, Finland
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23
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Göbel CH, Karstedt SC, Münte TF, Göbel H, Wolfrum S, Lebedeva ER, Olesen J, Royl G. ICHD-3 is significantly more specific than ICHD-3 beta for diagnosis of migraine with aura and with typical aura. J Headache Pain 2020; 21:2. [PMID: 31910800 PMCID: PMC6947981 DOI: 10.1186/s10194-019-1072-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/24/2019] [Indexed: 01/03/2023] Open
Abstract
Background In the emergency room, distinguishing between a migraine with aura and a transient ischemic attack (TIA) is often not straightforward and mistakes can be harmful to both the patient and to society. To account for this difficulty, the third edition of the International Classification of Headache disorders (ICHD-3) changed the diagnostic criteria of migraine with aura. Methods One hundred twenty-eight patients referred to the emergency room at the University Hospital of Lübeck, Germany with a suspected TIA were prospectively interviewed about their symptoms leading to admission shortly after initial presentation. The diagnosis that resulted from applying the ICHD-3 and ICHD-3 beta diagnostic criteria was compared to the diagnosis made independently by the treating physicians performing the usual diagnostic work-up. Results The new ICHD-3 diagnostic criteria for migraine with aura and migraine with typical aura display an excellent specificity (96 and 98% respectively), and are significantly more specific than the previous ICHD-3 beta classification system when it comes to diagnosing a first single attack (probable migraine with aura and probable migraine with typical aura). Conclusions The ICHD-3 is a highly useful tool for the clinical neurologist in order to distinguish between a migraine with aura and a TIA, already at the first point of patient contact, such as in the emergency department or a TIA clinic.
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Affiliation(s)
- Carl H Göbel
- Department of Neurology, University of Lübeck, 23538, Lübeck, Germany. .,Institute of Psychology II, University of Lübeck, 23538, Lübeck, Germany. .,Kiel Migraine and Headache Centre, 24149, Kiel, Germany.
| | - Sarah C Karstedt
- Department of Neurology, University of Lübeck, 23538, Lübeck, Germany.,Institute of Psychology II, University of Lübeck, 23538, Lübeck, Germany.,Kiel Migraine and Headache Centre, 24149, Kiel, Germany
| | - Thomas F Münte
- Department of Neurology, University of Lübeck, 23538, Lübeck, Germany.,Institute of Psychology II, University of Lübeck, 23538, Lübeck, Germany
| | - Hartmut Göbel
- Kiel Migraine and Headache Centre, 24149, Kiel, Germany
| | - Sebastian Wolfrum
- Interdisciplinary Emergency Department, University of Lübeck, 23538, Lübeck, Germany
| | - Elena R Lebedeva
- Department of Neurology, Ural State Medical University, Yekaterinburg, Russia
| | - Jes Olesen
- Danish Headache Center, Department of Neurology, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Georg Royl
- Department of Neurology, University of Lübeck, 23538, Lübeck, Germany.,Institute of Psychology II, University of Lübeck, 23538, Lübeck, Germany
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Chen S, Eikermann‐Haerter K. How Imaging Can Help Us Better Understand the Migraine‐Stroke Connection. Headache 2019; 60:217-228. [DOI: 10.1111/head.13664] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Shih‐Pin Chen
- Division of Translational Research Department of Medical Research Taipei Veterans General Hospital Taipei Taiwan
- Department of Neurology Neurological InstituteTaipei Veterans General Hospital Taipei Taiwan
- Institute of Clinical Medicine National Yang‐Ming University School of Medicine Taipei Taiwan
- Brain Research Center National Yang‐Ming University School of Medicine Taipei Taiwan
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Lima J, Mehta T, Datta N, Bakradze E, Staff I, Beland D, Nouh A. Migraine History: A Predictor of Negative Diffusion-Weighted Imaging in IV-tPA-Treated Stroke Mimics. J Stroke Cerebrovasc Dis 2019; 28:104282. [PMID: 31401044 DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/14/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Migraine, seizures, and psychiatric disorders are frequently reported as "stroke mimics" in patients with negative diffusion-weighted imaging (DWI) after IV-tPA. We sought to determine predictors of negative DWI in suspected stroke patients treated with IV-tPA. METHOD A retrospective case-control study encompassing all acute stroke patients treated with IV-tPA (at our hospital or "dripped and shipped") from January 2013 to December 2014 was con- ducted. A total of 275 patients were identified with 47 negative DWI cases and 228 positive DWI controls. Variables including demographic factors, stroke characteristics, and clinical comorbidities were analyzed for statistical significance. A multivariate logistic regression was performed (SPSS-24) to identify predictors of negative DWI. RESULTS Approximately 17% of patients had negative DWI after IV-tPA. Compared to controls, migraine history independently predicted negative DWI (odds ratio [OR] 5.0 95% confidence interval [CI] 1.03-24.6, P = .046). Increasing age (OR .97 95% CI .94-.99, P = .02) and atrial fibrillation (OR .25 95% CI .08-.77, P = .01) predicted lower probability of negative DWI. Gender, admission NIHSS, treatment location, preadmission modified Rankin scale, diabetes mellitus, hypertension, hyperlipidemia, symptom side, seizure history, and psychiatric history did not predict negative DWI status. CONCLUSIONS In our study, roughly 1 in 6 patients treated with IV-tPA were later found to be stroke mimics with negative DWI. Despite a high proportion of suspected stroke mimics in our study, only preexisting migraine history independently predicted negative DWI status after IV-tPA treatment in suspected stroke patients.
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Affiliation(s)
- Jussie Lima
- Ayer Neuroscience Institute, Hartford HealthCare, Hartford Hospital, Hartford, Connecticut; University of Connecticut, Hartford, Connecticut
| | - Tapan Mehta
- Ayer Neuroscience Institute, Hartford HealthCare, Hartford Hospital, Hartford, Connecticut; University of Connecticut, Hartford, Connecticut
| | - Neil Datta
- Ayer Neuroscience Institute, Hartford HealthCare, Hartford Hospital, Hartford, Connecticut; University of Connecticut, Hartford, Connecticut
| | - Ekaterina Bakradze
- Ayer Neuroscience Institute, Hartford HealthCare, Hartford Hospital, Hartford, Connecticut; University of Connecticut, Hartford, Connecticut
| | - Ilene Staff
- Ayer Neuroscience Institute, Hartford HealthCare, Hartford Hospital, Hartford, Connecticut; University of Connecticut, Hartford, Connecticut
| | - Dawn Beland
- Ayer Neuroscience Institute, Hartford HealthCare, Hartford Hospital, Hartford, Connecticut; University of Connecticut, Hartford, Connecticut
| | - Amre Nouh
- Ayer Neuroscience Institute, Hartford HealthCare, Hartford Hospital, Hartford, Connecticut; University of Connecticut, Hartford, Connecticut.
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26
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Abstract
PURPOSE OF REVIEW This review details the frequency of and ways in which migraine can be both an ischemic stroke/transient ischemic attack mimic (false positive) and chameleon (false negative). We additionally seek to clarify the complex relationships between migraine and cerebrovascular diseases with regard to diagnostic error. RECENT FINDINGS Nearly 2% of all patients evaluated emergently for possible stroke have an ultimate diagnosis of migraine; approximately 18% of all stroke mimic patients treated with intravenous thrombolysis have a final diagnosis of migraine. Though the treatment of a patient with migraine with thrombolytics confers a low risk of complication, symptomatic intracerebral hemorrhage may occur. Three clinical prediction scores with high sensitivity and specificity exist that can aid in the diagnosis of acute cerebral ischemia. Differentiating between migraine aura and transient ischemic attacks remains challenging. On the other hand, migraine is a common incorrect diagnosis initially given to patients with stroke. Among patients discharged from an emergency visit to home with a diagnosis of a non-specific headache disorder, 0.5% were misdiagnosed. Further development of tools to quantify and understand sources of stroke misdiagnosis among patients who present with headache is warranted. Both failure to identify cerebral ischemia among patients with headache and overdiagnosis of ischemia can lead to patient harms. While some tools exist to help with acute diagnostic decision-making, additional strategies to improve diagnostic safety among patients with migraine and/or cerebral ischemia are needed.
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Affiliation(s)
- Oleg Otlivanchik
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, Bronx, NY, 10467, USA
| | - Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, Bronx, NY, 10467, USA.
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27
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Viana M, Tronvik EA, Do TP, Zecca C, Hougaard A. Clinical features of visual migraine aura: a systematic review. J Headache Pain 2019; 20:64. [PMID: 31146673 PMCID: PMC6734223 DOI: 10.1186/s10194-019-1008-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/26/2019] [Indexed: 01/06/2023] Open
Abstract
Background Migraine aura (MA) is a common and disabling neurological condition, characterized by transient visual, and less frequently sensory and dysphasic aura disturbances. MA is associated with an increased risk of cardiovascular disorders and is often clinically difficult to distinguish from other serious neurological disorders such as transient ischemic attacks and epilepsy. Optimal clinical classification of MA symptoms is important for more accurate diagnosis and improved understanding of the pathophysiology of MA through clinical studies. Main body A systematic review of previous prospective and retrospective systematic recordings of visual aura symptoms (VASs) was performed to provide an overview of the different types of visual phenomena occurring during MA and their respective frequencies in patients. We found 11 retrospective studies and three prospective studies systematically describing VASs. The number of different types of VASs reported by patients in the studies ranged from two to 23. The most common were flashes of bright light, “foggy” vision, zigzag lines, scotoma, small bright dots and ‘like looking through heat waves or water’. Conclusions We created a comprehensive list of VAS types reported by migraine patients based on all currently available data from clinical studies, which can be used for testing and validation in future studies. We propose that, based on this work, an official list of VAS types should be developed, preferably within the context of the International Classification of Headache Disorders of the International Headache Society.
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Affiliation(s)
- Michele Viana
- Headache Center, Neurocenter of Southern Switzerland (NSI), Regional Hospital Lugano, Via Tesserete 46, 6901, Lugano, Switzerland. .,Headache Group, Department of Basic and Clinical Neurosciences, King's College London, London, UK.
| | - Erling Andreas Tronvik
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,Norwegian Advisory Unit on Headache, St. Olavs University Hospital, Trondheim, Norway
| | - Thien Phu Do
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Chiara Zecca
- Headache Center, Neurocenter of Southern Switzerland (NSI), Regional Hospital Lugano, Via Tesserete 46, 6901, Lugano, Switzerland.,Faculty of biomedical Sciences, Università della Svizzera Italiana, Via Buffi 13, 6900, Lugano, Switzerland
| | - Anders Hougaard
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Glostrup, Denmark
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28
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Magalhães JE, Sampaio Rocha-Filho PA. Migraine and cerebrovascular diseases: Epidemiology, pathophysiological, and clinical considerations. Headache 2018; 58:1277-1286. [DOI: 10.1111/head.13378] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 01/24/2023]
Affiliation(s)
- João Eudes Magalhães
- Postgraduate program in Neuropsychiatry and Behavioral Sciences, Universidade Federal de Pernambuco (UFPE); Pernambuco Brazil
- Stroke Clinic, Hospital Universitario Oswaldo Cruz, Universidade de Pernambuco (UPE); Recife Brazil
| | - Pedro Augusto Sampaio Rocha-Filho
- Department of Neuropsychiatry; Universidade Federal de Pernambuco (UFPE); Recife Brazil
- Headache Clinic, Hospital Universitario Oswaldo Cruz, Universidade de Pernambuco (UPE); Recife Brazil
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