TY  - GEN
AB  - Stroke mimics (SM) are non-vascular conditions that present with an acute neurological deficit simulating acute ischemic stroke and represent a significant percentage of all acute stroke hospital admissions. The most common clinical SM includes conversion/functional (psychiatric disorder); seizures and postictal paralysis; toxic-metabolic disturbances; brain tumours; infections, and migraine. Imaging is essential for SM recognition, being Diffusion weighted imaging (DWI), perfusion imaging and angiographic studies very useful. There are several disorders that may have imaging features that simulate acute ischemic stroke, mainly presenting with cytotoxic oedema and/or perfusion deficits. The imaging features of the most frequent clinical and imaging stroke mimics are reviewed.
AU  - Vilela, Pedro
DO  - 10.1016/j.ejrad.2017.05.008
KW  - Acute ischemic stroke
KW  - Migraine
KW  - Posterior Reversible Encephalopathy Syndrome PRES
KW  - Reversible Cerebral Vasoconstriction Syndrome RCVS
KW  - Seizures
KW  - Stroke mimic
KW  - Transient periictal MRI abnormalities TPMA
PY  - 2017
TI  - Acute stroke differential diagnosis: Stroke mimics
T2  - European Journal of Radiology
ER  -
TY  - JOUR
AB  - Background: Some patients seen by a stroke team do not have cerebrovascular disease but a condition that mimics stroke. The purpose of this study was to determine the rate and predictors of stroke mimics in a large sample. Methods: This is an analysis of data from consecutive patients seen by the National Institutes of Health Stroke Program over 10 years. Data were collected prospectively as a quality improvement initiative. Patients with a cerebrovascular event or a stroke mimic were compared with the Student t or Pearson chi-square test as appropriate, and logistic regression was done to identify independent predictors. Results: The analysis included 8187 patients: 30% had a stroke mimic. Patients with a stroke mimic were younger, and the proportion of patients with a stroke mimic was higher among women, patients without any risk factors, those seen as a code stroke or who arrived to the emergency department via personal vehicle, and those who had the onset of symptoms while inpatients. The proportion of patients with a stroke mimic was marginally higher among African-Americans than Caucasians. Factors associated with the greatest odds of having a stroke mimic in the logistic regression were lack of a history of hypertension, atrial fibrillation or hyperlipidemia. Conclusions: One third of the patients seen by a stroke team over 10 years had a stroke mimic. Factors associated with a stroke mimic may be ascertained by an emergency physician before calling the stroke team. © 2013 Elsevier B.V. All rights reserved.
AU  - Merino, José G.
AU  - Luby, Marie
AU  - Benson, Richard T.
AU  - Davis, Lisa A.
AU  - Hsia, Amie W.
AU  - Latour, Lawrence L.
AU  - Lynch, John K.
AU  - Warach, Steven
DO  - 10.1016/j.jstrokecerebrovasdis.2013.04.018
KW  - Acute stroke
KW  - diagnosis
KW  - emergency medicine
KW  - stroke mimics
PY  - 2013
TI  - Predictors of acute stroke mimics in 8187 patients referred to a stroke service
T2  - Journal of Stroke and Cerebrovascular Diseases
ER  -
TY  - JOUR
AU  - Prevention, Centers for disease control and
PY  - 2020
TI  - Stroke Facts
ER  -
TY  - JOUR
AB  - Background: Treatment decisions for patients with acute stroke symptoms are based on pertinent history, neurologic examination, laboratory studies, and head computed tomography. In this setting, patients with stroke mimic (SM) may mistakenly receive intravenous tissue plasminogen activator (IV-rtPA). The goal of this study was to investigate the excess direct/indirect hospital costs among patients who received IV-rtPA when final diagnosis was not ischemic stroke. Methods: We reviewed the records of 535 IV-rtPA-treated patients who presented to our primary stroke centers. The diagnosis of SM or transient ischemic attack (TIA) was based on patient presentation, hospital course, electroencephalography, and negative neuroimaging studies. The excess cost analysis compared actual direct and indirect hospital costs of a patient to what their direct and indirect hospital costs would have been had they primarily been diagnosed with mimic or TIA. Results: Seventy-four patients post-IV-rtPA treatment had final diagnosis of SM; 21 had TIAs. The excess direct and indirect hospital costs for mimics were $257,975 and $152,813, respectively. The median excess cost was $5401 per admission. The excess total cost for TIAs was $85,026 with a median of $3407 per admission. Conclusions: Administration of IV-rtPA to patients with SMs remains prevalent and costly. Certain clinical or radiographic characteristics can help diagnose mimics; however, more studies need to be done to determine the feasibility and effectiveness of further clinical investigations among suspected SM patients who are within the thrombolysis treatment window.
AU  - Goyal, Nitin
AU  - Male, Shailesh
AU  - Al Wafai, Ameer
AU  - Bellamkonda, Sushma
AU  - Zand, Ramin
DO  - 10.1016/j.jstrokecerebrovasdis.2014.11.023
KW  - Cost burden
KW  - Intravenous thrombolysis
KW  - Stroke
KW  - Stroke mimics
KW  - TIA
PY  - 2015
TI  - Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment
T2  - Journal of Stroke and Cerebrovascular Diseases
ER  -
TY  - JOUR
AB  - Background Stroke is a leading cause of death and disability and most commonly presents with focal neurologic deficit within a specific vascular distribution. Several other conditions may present in a similar manner. Objectives This review provides emergency providers with an understanding of stroke mimics, use of thrombolytics in these mimics, and keys to differentiate true stroke from mimic. Discussion Stroke has significant morbidity and mortality, and the American Heart Association emphasizes rapid recognition and aggressive treatment for patients with possible stroke-like symptoms, including thrombolytics. However, many conditions mimic the presentation of stroke, with up to a 31% rate of misdiagnosis, leading to potentially harmful treatment. Stroke mimics are conditions that present with stroke-like symptoms, including seizures, headaches, metabolic, infection, space-occupying lesion, neurodegenerative disorder, peripheral neuropathy, syncope, vascular disorder, and functional disorder. Factors of history and physical examination supporting stroke vs. mimic are discussed, though any sudden-onset, objective, focal neurologic deficit in a patient should be assumed acute stroke until proven otherwise. Head computed tomography noncontrast is the first-line imaging modality. Magnetic resonance imaging is the most sensitive and specific imaging modality. Neurology consultation is recommended in the majority of patients. If stroke is suspected after evaluation, shared decision-making for further management and consideration of thrombolytics is recommended. Conclusions Stroke mimics present a conundrum for emergency providers. A new focal neurologic deficit warrants rapid evaluation for stroke with neuroimaging and neurology consultation. Several mimics found on assessment may resolve with treatment.
AU  - Long, Brit
AU  - Koyfman, Alex
DO  - 10.1016/j.jemermed.2016.09.021
KW  - cerebrovascular accident
KW  - chameleon
KW  - encephalopathy
KW  - headache
KW  - hypoglycemia
KW  - mimic
KW  - neurodegenerative
KW  - peripheral neuropathy
KW  - seizure
KW  - stroke
KW  - thrombolytics
PY  - 2017
TI  - Clinical Mimics: An Emergency Medicine-Focused Review of Stroke Mimics
T2  - Journal of Emergency Medicine
ER  -
TY  - GEN
AU  - Stroke, National institute of neurological disorders and
PY  - 2019
TI  - stroke information page
T2  - stroke information page
UR  - https://www.ninds.nih.gov/Disorders/All-Disorders/Stroke-Information-Page#disorders-r2
ER  -
TY  - JOUR
AB  - BACKGROUND The lifetime risk of stroke has been calculated in a limited number of selected populations. We sought to estimate the lifetime risk of stroke at the regional, country, and global level using data from a comprehensive study of the prevalence of major diseases. METHODS We used the Global Burden of Disease (GBD) Study 2016 estimates of stroke incidence and the competing risks of death from any cause other than stroke to calculate the cumulative lifetime risks of first stroke, ischemic stroke, or hemorrhagic stroke among adults 25 years of age or older. Estimates of the lifetime risks in the years 1990 and 2016 were compared. Countries were categorized into quintiles of the sociodemographic index (SDI) used in the GBD Study, and the risks were compared across quintiles. Comparisons were made with the use of point estimates and uncertainty intervals representing the 2.5th and 97.5th percentiles around the estimate. RESULTS The estimated global lifetime risk of stroke from the age of 25 years onward was 24.9% (95% uncertainty interval, 23.5 to 26.2); the risk among men was 24.7% (95% uncertainty interval, 23.3 to 26.0), and the risk among women was 25.1% (95% uncertainty interval, 23.7 to 26.5). The risk of ischemic stroke was 18.3%, and the risk of hemorrhagic stroke was 8.2%. In high-SDI, high-middle-SDI, and low- SDI countries, the estimated lifetime risk of stroke was 23.5%, 31.1% (highest risk), and 13.2% (lowest risk), respectively; the 95% uncertainty intervals did not overlap between these categories. The highest estimated lifetime risks of stroke according to GBD region were in East Asia (38.8%), Central Europe (31.7%), and Eastern Europe (31.6%), and the lowest risk was in eastern sub-Saharan Africa (11.8%). The mean global lifetime risk of stroke increased from 22.8% in 1990 to 24.9% in 2016, a relative increase of 8.9% (95% uncertainty interval, 6.2 to 11.5); the competing risk of death from any cause other than stroke was considered in this calculation. CONCLUSIONS In 2016, the global lifetime risk of stroke from the age of 25 years onward was approximately 25% among both men and women. There was geographic variation in the lifetime risk of stroke, with the highest risks in East Asia, Central Europe, and Eastern Europe.
AU  - Roth, Gregory A.
AU  - Feigin, Valery L.
AU  - Nguyen, Grant
AU  - Cercy, Kelly
AU  - Johnson, Catherine O.
AU  - Alam, Tahiya
AU  - Parmar, Priyakumari G.
AU  - Abajobir, Amanuel A.
AU  - Abate, Kalkidan H.
AU  - Abd-Allah, Foad
AU  - Abejie, Ayenew N.
AU  - Abyu, Gebre Y.
AU  - Ademi, Zanfina
AU  - Agarwal, Gina
AU  - Ahmed, Muktar B.
AU  - Akinyemi, Rufus O.
AU  - Al-Raddadi, Rajaa
AU  - Aminde, Leopold N.
AU  - Amlie-Lefond, Catherine
AU  - Ansari, Hossein
AU  - Asayesh, Hamid
AU  - Asgedom, Solomon W.
AU  - Atey, Tesfay M.
AU  - Ayele, Henok T.
AU  - Banach, Maciej
AU  - Banerjee, Amitava
AU  - Barac, Aleksandra
AU  - Barker-Collo, Suzanne L.
AU  - Bärnighausen, Till
AU  - Barregard, Lars
AU  - Basu, Sanjay
AU  - Bedi, Neeraj
AU  - Behzadifar, Masoud
AU  - Béjot, Yannick
AU  - Bennett, Derrick A.
AU  - Bensenor, Isabela M.
AU  - Berhe, Derbew F.
AU  - Boneya, Dube J.
AU  - Brainin, Michael
AU  - Campos-Nonato, Ismael R.
AU  - Caso, Valeria
AU  - Castañeda-Orjuela, Carlos A.
AU  - Rivas, Jacquelin C.
AU  - Catalá-López, Ferrán
AU  - Christensen, Hanne
AU  - Criqui, Michael H.
AU  - Damasceno, Albertino
AU  - Dandona, Lalit
AU  - Dandona, Rakhi
AU  - Davletov, Kairat
AU  - de Courten, Barbora
AU  - deVeber, Gabrielle
AU  - Dokova, Klara
AU  - Edessa, Dumessa
AU  - Endres, Matthias
AU  - Faraon, Emerito J.A.
AU  - Farvid, Maryam S.
AU  - Fischer, Florian
AU  - Foreman, Kyle
AU  - Forouzanfar, Mohammad H.
AU  - Gall, Seana L.
AU  - Gebrehiwot, Tsegaye T.
AU  - Geleijnse, Johanna M.
AU  - Gillum, Richard F.
AU  - Giroud, Maurice
AU  - Goulart, Alessandra C.
AU  - Gupta, Rahul
AU  - Gupta, Rajeev
AU  - Hachinski, Vladimir
AU  - Hamadeh, Randah R.
AU  - Hankey, Graeme J.
AU  - Hareri, Habtamu A.
AU  - Havmoeller, Rasmus
AU  - Hay, Simon I.
AU  - Hegazy, Mohamed I.
AU  - Hibstu, Desalegn T.
AU  - James, Spencer L.
AU  - Jeemon, Panniyammakal
AU  - John, Denny
AU  - Jonas, Jost B.
AU  - Jóźwiak, Jacek
AU  - Kalani, Rizwan
AU  - Kandel, Amit
AU  - Kasaeian, Amir
AU  - Kengne, Andre P.
AU  - Khader, Yousef S.
AU  - Khan, Abdur R.
AU  - Khang, Young Ho
AU  - Khubchandani, Jagdish
AU  - Kim, Daniel
AU  - Kim, Yun J.
AU  - Kivimaki, Mika
AU  - Kokubo, Yoshihiro
AU  - Kolte, Dhaval
AU  - Kopec, Jacek A.
AU  - Kosen, Soewarta
AU  - Kravchenko, Michael
AU  - Krishnamurthi, Rita
AU  - Anil Kumar, G.
AU  - Lafranconi, Alessandra
AU  - Lavados, Pablo M.
AU  - Legesse, Yirga
AU  - Li, Yongmei
AU  - Liang, Xiaofeng
AU  - Lo, Warren D.
AU  - Lorkowski, Stefan
AU  - Lotufo, Paulo A.
AU  - Loy, Clement T.
AU  - Mackay, Mark T.
AU  - Abd El Razek, Hassan Magdy
AU  - Mahdavi, Mahdi
AU  - Majeed, Azeem
AU  - Malekzadeh, Reza
AU  - Malta, Deborah C.
AU  - Mamun, Abdullah A.
AU  - Mantovani, Lorenzo G.
AU  - Martins, Sheila C.O.
AU  - Mate, Kedar K.
AU  - Mazidi, Mohsen
AU  - Mehata, Suresh
AU  - Meier, Toni
AU  - Melaku, Yohannes A.
AU  - Mendoza, Walter
AU  - Mensah, George A.
AU  - Meretoja, Atte
AU  - Mezgebe, Haftay B.
AU  - Miazgowski, Tomasz
AU  - Miller, Ted R.
AU  - Ibrahim, Norlinah M.
AU  - Mohammed, Shafiu
AU  - Mokdad, Ali H.
AU  - Moosazadeh, Mahmood
AU  - Moran, Andrew E.
AU  - Musa, Kamarul I.
AU  - Negoi, Ruxandra I.
AU  - Nguyen, Minh
AU  - Nguyen, Quyen L.
AU  - Nguyen, Trang H.
AU  - Tran, Tung T.
AU  - Nguyen, Thanh T.
AU  - Anggraini Ningrum, Dina Nur
AU  - Norrving, Bo
AU  - Noubiap, Jean J.
AU  - O'Donnell, Martin J.
AU  - Olagunju, Andrew T.
AU  - Onuma, Oyere K.
AU  - Owolabi, Mayowa O.
AU  - Parsaeian, Mahboubeh
AU  - Patton, George C.
AU  - Piradov, Michael
AU  - Pletcher, Martin A.
AU  - Pourmalek, Farshad
AU  - Prakash, V.
AU  - Qorbani, Mostafa
AU  - Rahman, Mahfuzar
AU  - Rahman, Muhammad A.
AU  - Rai, Rajesh K.
AU  - Ranta, Annemarei
AU  - Rawaf, David
AU  - Rawaf, Salman
AU  - Renzaho, Andre M.N.
AU  - Robinson, Stephen R.
AU  - Sahathevan, Ramesh
AU  - Sahebkar, Amirhossein
AU  - Salomon, Joshua A.
AU  - Santalucia, Paola
AU  - Santos, Itamar S.
AU  - Sartorius, Benn
AU  - Schutte, Aletta E.
AU  - Sepanlou, Sadaf G.
AU  - Shafieesabet, Azadeh
AU  - Shaikh, Masood A.
AU  - Shamsizadeh, Morteza
AU  - Sheth, Kevin N.
AU  - Sisay, Mekonnen
AU  - Shin, Min Jeong
AU  - Shiue, Ivy
AU  - Silva, Diego A.S.
AU  - Sobngwi, Eugene
AU  - Soljak, Michael
AU  - Sorensen, Reed J.D.
AU  - Sposato, Luciano A.
AU  - Stranges, Saverio
AU  - Suliankatchi, Rizwan A.
AU  - Tabarés-Seisdedos, Rafael
AU  - Tanne, David
AU  - Tat Nguyen, Cuong
AU  - Thakur, J. S.
AU  - Thrift, Amanda G.
AU  - Tirschwell, David L.
AU  - Topor-Madry, Roman
AU  - Tran, Bach X.
AU  - Nguyen, Luong T.
AU  - Truelsen, Thomas
AU  - Tsilimparis, Nikolaos
AU  - Tyrovolas, Stefanos
AU  - Ukwaja, Kingsley N.
AU  - Uthman, Olalekan A.
AU  - Varakin, Yuri
AU  - Vasankari, Tommi
AU  - Venketasubramanian, Narayanaswamy
AU  - Vlassov, Vasiliy V.
AU  - Wang, Wenzhi
AU  - Werdecker, Andrea
AU  - Wolfe, Charles D.A.
AU  - Xu, Gelin
AU  - Yano, Yuichiro
AU  - Yonemoto, Naohiro
AU  - Yu, Chuanhua
AU  - Zaidi, Zoubida
AU  - El Sayed Zaki, Maysaa
AU  - Zhou, Maigeng
AU  - Ziaeian, Boback
AU  - Zipkin, Ben
AU  - Vos, Theo
AU  - Naghavi, Mohsen
AU  - Murray, Christopher J.L.
DO  - 10.1056/NEJMoa1804492
PY  - 2018
TI  - Global, regional, and country-specific lifetime risks of stroke, 1990 and 2016
T2  - New England Journal of Medicine
ER  -
TY  - JOUR
AB  - Background and Purpose-Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden. Methods-Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. Results-The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people 65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions. Conclusions-The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality. © 2013 American Heart Association, Inc.
AU  - Lackland, Daniel T.
AU  - Roccella, Edward J.
AU  - Deutsch, Anne F.
AU  - Fornage, Myriam
AU  - George, Mary G.
AU  - Howard, George
AU  - Kissela, Brett M.
AU  - Kittner, Steven J.
AU  - Lichtman, Judith H.
AU  - Lisabeth, Lynda D.
AU  - Schwamm, Lee H.
AU  - Smith, Eric E.
AU  - Towfighi, Amytis
DO  - 10.1161/01.str.0000437068.30550.cf
KW  - AHA Scientific Statements
KW  - Diabetes mellitus
KW  - Hyperlipidemias
KW  - Hypertension
KW  - Risk factors
KW  - Stroke
PY  - 2014
TI  - Factors influencing the decline in stroke mortality a statement from the american heart association/american stroke association
T2  - Stroke
ER  -
TY  - JOUR
AB  - Carga de enfermedad por enfermedades crónicas no transmisibles y discapacidad en Colombia
AU  - Ministerio de Salud
AU  - Instituto Nacional de Salud
AU  - Observatorio Nacional de Salud
DO  - http://www.ins.gov.co/lineas-de-accion/ons/SiteAssets/Paginas/publicaciones/5to%20Informe%20ONS%20v-f1.pdf
PY  - 2015
SN  - 2346-3325
TI  - Carga de enfermedad por enfermedades crónicas no transmisibles y discapacidad en Colombia
T2  - Observatorio Nacional de Salud
ER  -
TY  - JOUR
AB  - Background: Socioeconomic status (SES) is associated with stroke incidence and mortality. Distribution of stroke risk factors is changing worldwide; evidence on these trends is crucial to the allocation of resources for prevention strategies to tackle major modifiable risk factors with the highest impact on stroke burden. Methods: We extracted data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. We analysed trends in global and SES-specific age-standardised stroke incidence, prevalence, mortality, and disability-adjusted life years (DALYs) lost from 1990 to 2017. We also estimated the age-standardised attributable risk of stroke mortality associated with common risk factors in low-, low-middle-, upper-middle-, and high-income countries. Further, we explored the effect of age and sex on associations of risk factors with stroke mortality from 1990 to 2017. Results: Despite a growth in crude number of stroke events from 1990 to 2017, there has been an 11.3% decrease in age-standardised stroke incidence rate worldwide (150.5, 95% uncertainty interval [UI] 140.3-161.8 per 100,000 in 2017). This has been accompanied by an overall 3.1% increase in age-standardised stroke prevalence rate (1300.6, UI 1229.0-1374.7 per 100,000 in 2017) and a 33.4% decrease in age-standardised stroke mortality rate (80.5, UI 78.9-82.6 per 100,000 in 2017) over the same time period. The rising trends in age-standardised stroke prevalence have been observed only in middle-income countries, despite declining trends in age-standardised stroke incidence and mortality in all income categories since 2005. Further, there has been almost a 34% reduction in stroke death rate (67.8, UI 64.1-71.1 per 100,000 in 2017) attributable to modifiable risk factors, more prominently in wealthier countries. Conclusions: Almost half of stroke-related deaths are attributable to poor management of modifiable risk factors, and thus potentially preventable. We should appreciate societal barriers in lower-SES groups to design tailored preventive strategies. Despite improvements in general health knowledge, access to healthcare, and preventative strategies, SES is still strongly associated with modifiable risk factors and stroke burden; thus, screening of people from low SES at higher stroke risk is crucial.
AU  - Avan, Abolfazl
AU  - Digaleh, Hadi
AU  - Di Napoli, Mario
AU  - Stranges, Saverio
AU  - Behrouz, Reza
AU  - Shojaeianbabaei, Golnaz
AU  - Amiri, Amin
AU  - Tabrizi, Reza
AU  - Mokhber, Naghmeh
AU  - Spence, J. David
AU  - Azarpazhooh, Mahmoud Reza
DO  - 10.1186/s12916-019-1397-3
KW  - Cause of death
KW  - Global burden of disease
KW  - Global health
KW  - Life style
KW  - Morbidity
KW  - Non-communicable diseases
KW  - Public health practice
KW  - Risk factors
KW  - Socioeconomic factors
KW  - Stroke
PY  - 2019
TI  - Socioeconomic status and stroke incidence, prevalence, mortality, and worldwide burden: An ecological analysis from the Global Burden of Disease Study 2017
T2  - BMC Medicine
ER  -
TY  - JOUR
AB  - Background & Objectives: Stroke mimics are conditions that simulate the signs and symptoms of a stroke. These conditions pose a clinical challenge as they need to be distinguished from actual strokes based on neurologic findings, laboratory tests, and imaging studies in order to minimize the adverse effects of acute stroke therapies as well as hospital costs. The study aims to determine the rate and the most common etiologies of stroke mimics in a private tertiary care hospital in the Philippines and calculate the average cost incurred for diagnostics. Methods: We conducted a retrospective review of medical records of adult patients assessed by the hospital’s Brain Attack Team from 1 January 2014 to 31 December 2017. The diagnosis of stroke mimic was based on negative neuroimaging findings and laboratory results that showed an alternate diagnosis, in consultation with the stroke neurologist on call. Results: A total of 1,485 patient records were analyzed; 448 patients (30.2%) were diagnosed as stroke mimics. The most common etiologies were encephalopathy (83 cases, 18.5%), seizures (77 cases, 17.2%), headache (31 cases, 6.9%), hypertensive emergency (31 cases, 6.9%), and radiculopathy (27 cases, 6.0%). The average cost for diagnostics for each patient diagnosed as a stroke mimic was PHP 24,629.53 (approximately US$500). Conclusion: Stroke mimics are often encountered in the emergency setting. Due to the wide range of medical conditions that mimic stroke, early recognition is important in order to avoid the potential adverse effects of acute stroke therapies and minimize diagnostic costs, particularly in countries with limited resources.
AU  - Ocampo, Ferron F.
AU  - De Leon-Gacrama, Francesca Rose G.
AU  - Cuanang, Joven R.
AU  - Navarro, Jose C.
IS  - 1
PY  - 2021
TI  - Profile of stroke mimics in a tertiary medical center in the Philippines
T2  - Neurology Asia
VL  - 26
ER  -
TY  - JOUR
AB  - Background and Purpose: The etiology of ischemic stroke affects prognosis, outcome, and management. Trials of therapies for patients with acute stroke should include measurements of responses as influenced by subtype of ischemic stroke. A system for categorization of subtypes of ischemic stroke mainly based on etiology has been developed for the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Methods: A classification of subtypes was prepared using clinical features and the results of ancillary diagnostic studies. "Possible" and "probable" diagnoses can be made based on the physician's certainty testedbytwoneurologists who had not participated in the writing of the criteria. The neurologists independently used the TOAST clinicalfeaturesand then after reviewing the results of diagnostic tests. Results: The TOAST classification denotes five subtypes of ischemic stroke: 1) large-artery atheroscle- rosis, 2) cardioembolism, 3) small-vessel occlusion, 4) stroke of other determined etiology, and 5) stroke of undetermined etiology. Using this rating system, interphysician agreement was very high. The two physicians disagreed in only one patient. They were both able to reach a specific etiologic diagnosis in 11 patients, whereas the cause of stroke was not determined in nine. Conclusions: The TOAST stroke subtype classification system is easy to use and has good interobserver agreement. This system should allow investigators to report responses to treatment among important subgroups of patients with ischemic stroke. Clinical trials testing treatments for acute ischemic stroke should include similar methods to diagnose subtypes of stroke. (Stroke 1993;24:35-41)
AU  - Adams, H.P
AU  - Adams, H.P
AU  - Bendixen, B.H
AU  - Bendixen, B.H
AU  - Kappelle, L.J
AU  - Kappelle, L.J
AU  - Biller, J.
AU  - Biller, J.
AU  - Love, B.B
AU  - Love, B.B
AU  - Gordon, D.L
AU  - Gordon, D.L
AU  - Marsh, E.E
AU  - Marsh, E.E
KW  - but definitions are
KW  - c ategorization of subtypes
KW  - cerebral ischemia
KW  - classification
KW  - clinical trials
KW  - had considerable study
KW  - hard to formulate and
KW  - of ischemic stroke has
KW  - their application for
PY  - 1993
TI  - Classification of Subtype of Acute Ischemic Stroke
T2  - Stroke
ER  -
TY  - JOUR
AB  - This article reviews published stroke subtype classification systems and offers rules and a basis for a new way to subtype stroke patients. Stroke subtyping can have different purposes, e.g. describing patients' characteristics in a clinical trial, grouping patients in an epidemiological study, careful phenotyping of patients in a genetic study, and classifying patients for therapeutic decision-making in daily practice. The classification should distinguish between ischemic and hemorrhagic stroke, subarachnoid hemorrhage, cerebral venous thrombosis, and spinal cord stroke. Regarding the 4 main categories of etiologies of ischemic stroke (i.e. atherothrombotic, small vessel disease, cardioembolic, and other causes), the classification should reflect the most likely etiology without neglecting the vascular conditions that are also found (e.g. evidence of small vessel disease in the presence of severe large vessel obstructions). Phenotypes of large cohorts can also be characterized by surrogate markers or intermediate phenotypes (e.g. presence of internal carotid artery plaque, intima-media thickness of the common carotid artery, leukoaraiosis, microbleeds, or multiple lacunae). Parallel classifications (i.e. surrogate markers) may serve as within-study abnormalities to support research findings. Copyright © 2009 S. Karger AG, Basel.
AU  - Amarenco, P.
AU  - Bogousslavsky, J.
AU  - Caplan, L. R.
AU  - Donnan, G. A.
AU  - Hennerici, M. G.
DO  - 10.1159/000210432
KW  - Classification systems
KW  - Review
KW  - Stroke
PY  - 2009
TI  - Classification of stroke subtypes
T2  - Cerebrovascular Diseases
ER  -
TY  - GEN
AB  - In this review, we have summarized the findings of fifteen studies of knowledge of stroke warning signs and risk factors in both high- and low-risk populations. In general, there appears to be low levels of knowledge of both risk factors and stroke warning signs among the communities studied. Using free recall, between 20% and 30% of respondents could not name a single risk factor, and between 10% and 60% could not name a single warning sign of stroke. Providing survey respondents with a list of potential warning signs substantially improved the identification of warning signs. Respondents in older age groups and having lower levels of educational attainment tended to have less knowledge of risk factors and warning signs of stroke than those in younger age groups and those with more education. Public campaigns to improve stroke knowledge are needed, particularly in the older age groups where the risk of stroke is greater.
AU  - Nicol, Marcus B.
AU  - Thrift, Amanda G.
DO  - 10.2147/vhrm.1.2.137.64085
PY  - 2005
TI  - Knowledge of risk factors and warning signs of stroke.
T2  - Vascular health and risk management
ER  -
TY  - JOUR
AB  - BACKGROUND AND PURPOSE - Few acute stroke patients are treated with alteplase, partly because of significant prehospital delays after symptom onset. The aim of this study was to determine among ambulance-transported stroke patients factors associated with stroke recognition and factors associated with a call for ambulance assistance within 1 hour from symptom onset. METHODS - For 6 months in 2004, all ambulance-transported stroke or transient ischemic attack patients arriving from a geographically defined region in Melbourne (Australia) to 1 of 3 hospital emergency departments were assessed. Tapes of the call for ambulance assistance were analyzed and the patient and the caller were interviewed. RESULTS - One hundred ninety-eight patients were included in the study. Stroke was reported as the problem in 44% of ambulance calls. Unprompted stroke recognition was independently associated with facial droop (P=0.015) and a history of stroke or transient ischemic attack (P<0.001). More than half of the calls for ambulance assistance were made within 1 hour from symptom onset and only 43% of these callers spontaneously identified the problem as "stroke." Factors independently associated with a call within 1 hour were: speech problems (P=0.009), caller family history of stroke (P=0.017), and the patient was not alone at symptom onset (P=0.018). CONCLUSIONS - Stroke was reported as the problem (unprompted) by <50% of callers. Fewer than half the calls were made within 1 hour from symptom onset. Interventions are needed to more strongly link stroke recognition to immediate action and increase the number of stroke patients eligible for acute treatment. © 2007 American Heart Association, Inc.
AU  - Mosley, Ian
AU  - Nicol, Marcus
AU  - Donnan, Geoffrey
AU  - Patrick, Ian
AU  - Dewey, Helen
DO  - 10.1161/01.STR.0000254528.17405.cc
KW  - Acute stroke
KW  - Community awareness
KW  - Emergency medical services
KW  - Paramedics
PY  - 2007
TI  - Stroke symptoms and the decision to call for an ambulance
T2  - Stroke
ER  -
TY  - GEN
AU  - Musuka, Tapuwa D.
AU  - Wilton, Stephen B.
AU  - Traboulsi, Mouhieddin
AU  - Hill, Michael D.
DO  - 10.1503/cmaj.140355
PY  - 2015
TI  - Diagnosis and management of acute ischemic stroke: Speed is critical
T2  - CMAJ
ER  -
TY  - JOUR
AB  - Background and Purpose—The FAST algorithm (Face, Arm, Speech, Time) helps identify persons having an acute stroke. We determined the proportion of patients with acute ischemic stroke not captured by FAST and evaluated a revised mnemonic. Methods—Records of all patients admitted to the University of Kentucky Stroke Center between January and December 2014 with a discharge International Classification of Diseases, Ninth Revision, Clinical Modification code for acute ischemic stroke were reviewed. Those misclassified, having missing National Institutes of Health Stroke Scale data, or were comatose or intubated were excluded. Presenting symptoms, demographics, and examination findings based on the National Institutes of Health Stroke Scale data were abstracted. Results—Of 858 consecutive records identified, 736 met inclusion criteria; 14.1% did not have any FAST symptoms at presentation. Of these, 42% had gait imbalance or leg weakness, 40% visual symptoms, and 70% either symptom. With their addition, the pro...
AU  - Aroor, Sushanth
AU  - Singh, Rajpreet
AU  - Goldstein, Larry B.
DO  - 10.1161/strokeaha.116.015169
PY  - 2017
TI  - BE-FAST (Balance, Eyes, Face, Arm, Speech, Time)
T2  - Stroke
ER  -
TY  - GEN
AU  - Julie Fussner, Cesar Velasco
PY  - 2019
SP  - 1
EP  - 23
TI  - ASSESSING STROKE – SCORES & SCALES
T2  - American Stroke Association
ER  -
TY  - JOUR
AB  - Background and Purpose-Patients with acute ischemic stroke (AIS) and large vessel occlusion may benefit from direct transportation to an endovascular capable comprehensive stroke center (mothership approach) as opposed to direct transportation to the nearest stroke unit without endovascular therapy (drip and ship approach). The optimal transport strategy for patients with AIS and unknown vessel status is uncertain. The rapid arterial occlusion evaluation scale (RACE, scores ranging from 0 to 9, with higher scores indicating higher stroke severity) correlates with the National Institutes of Health Stroke Scale and was developed to identify patients with large vessel occlusion in a prehospital setting. We evaluate how the RACE scale can help to inform prehospital triage decisions for AIS patients. Methods-In a model-based approach, we estimate probabilities of good outcome (modified Rankin Scale score of ≤2 at 3 months) as a function of severity of stroke symptoms and transport times for the mothership approach and the drip and ship approach. We use these probabilities to obtain optimal RACE cutoff scores for different transfer time settings and combinations of treatment options (time-based eligibility for secondary transfer under the drip and ship approach, time-based eligibility for thrombolysis at the comprehensive stroke center under the mothership approach). Results-In our model, patients with AIS are more likely to benefit from direct transportation to the comprehensive stroke center if they have more severe strokes. Values of the optimal RACE cutoff scores range from 0 (mothership for all patients) to >9 (drip and ship for all patients). Shorter transfer times and longer door-to-needle and needle-to-transfer (door out) times are associated with lower optimal RACE cutoff scores. Conclusions-Use of RACE cutoff scores that take into account transport times to triage AIS patients to the nearest appropriate hospital may lead to improved outcomes. Further studies should examine the feasibility of translation into clinical practice.
AU  - Schlemm, Eckhard
AU  - Ebinger, Martin
AU  - Nolte, Christian H.
AU  - Endres, Matthias
AU  - Schlemm, Ludwig
DO  - 10.1161/STROKEAHA.117.017281
KW  - emergency medical services
KW  - probability
KW  - stroke
KW  - thrombectomy
KW  - triage
PY  - 2017
TI  - Optimal Transport Destination for Ischemic Stroke Patients with Unknown Vessel Status: Use of Prehospital Triage Scores
T2  - Stroke
ER  -
TY  - JOUR
AB  - BACKGROUND The National Institutes of Health Stroke Scale (NIHSS), a well-validated tool for assessing initial stroke severity, has previously been shown to be associated with mortality in acute ischemic stroke. However, the relationship, optimal categorization, and risk discrimination with the NIHSS for predicting 30-day mortality among Medicare beneficiaries with acute ischemic stroke has not been well studied. METHODS AND RESULTS We analyzed data from 33102 fee-for-service Medicare beneficiaries treated at 404 Get With The Guidelines-Stroke hospitals between April 2003 and December 2006 with NIHSS documented. The 30-day mortality rate by NIHSS as a continuous variable and by risk-tree determined or prespecified categories were analyzed, with discrimination of risk quantified by the c-statistic. In this cohort, mean age was 79.0 years and 58% were female. The median NIHSS score was 5 (25th to 75th percentile 2 to 12). There were 4496 deaths in the first 30 days (13.6%). There was a strong graded relation between increasing NIHSS score and higher 30-day mortality. The 30-day mortality rates for acute ischemic stroke by NIHSS categories were as follows: 0 to 7, 4.2%; 8 to 13, 13.9%; 14 to 21, 31.6%; 22 to 42, 53.5%. A model with NIHSS alone provided excellent discrimination whether included as a continuous variable (c-statistic 0.82 [0.81 to 0.83]), 4 categories (c-statistic 0.80 [0.79 to 0.80]), or 3 categories (c-statistic 0.79 [0.78 to 0.79]). CONCLUSIONS The NIHSS provides substantial prognostic information regarding 30-day mortality risk in Medicare beneficiaries with acute ischemic stroke. This index of stroke severity is a very strong discriminator of mortality risk, even in the absence of other clinical information, whether used as a continuous or categorical risk determinant. (J Am Heart Assoc. 2012;1:42-50.).
AU  - Fonarow, Gregg C.
AU  - Saver, Jeffrey L.
AU  - Smith, Eric E.
AU  - Broderick, Joseph P.
AU  - Kleindorfer, Dawn O.
AU  - Sacco, Ralph L.
AU  - Pan, Wenqin
AU  - Olson, DaiWai M.
AU  - Hernandez, Adrian F.
AU  - Peterson, Eric D.
AU  - Schwamm, Lee H.
DO  - 10.1161/jaha.111.000034
PY  - 2012
TI  - Relationship of National Institutes of Health Stroke Scale to 30‐Day Mortality in Medicare Beneficiaries With Acute Ischemic Stroke
T2  - Journal of the American Heart Association
ER  -
TY  - JOUR
AB  - Background: Physicians are often asked to predict outcome after acute stroke. Very little information is available that can reliably predict the likelihood of severe disability or death. Objective: To develop a practical method for predicting a poor outcome after acute ischemic stroke. Methods: Data from the placebo arms of Parts 1 and 2 of the National Institute of Neurological Disorders and Stroke rt-PA [recombinant tissue plasminogen activator] Stroke Trial were used to identify variables that could predict a poor outcome, defined as moderately severe disability, severe disability, or death (Modified Rankin Scale score >3) 3 months after stroke. Results: Baseline variables that predicted poor outcome were the NIH Stroke Scale (NIHSS) >17 plus atrial fibrillation, yielding a positive predictive value (PPV) of 96% (95% CI, 88 to 100%). The best predictor at 24 hours was NIHSS >22, yielding a PPV of 98% (95% CI, 93 to 100%). The best predictor at 7 to 10 days was NIHSS >16, yielding a PPV of 92% (95% CI, 85 to 99%). Conclusions: Patients with a severe neurologic deficit after acute ischemic stroke, as measured by the NIHSS, have a poor prognosis. During the first week after acute ischemic stroke, it is possible to identify a subset of patients who are highly likely to have a poor outcome. These findings require confirmation in a separate study.
AU  - Frankel, Michael R.
AU  - Morgenstern, L. B.
AU  - Kwiatkowski, T.
AU  - Lu, M.
AU  - Tilley, B. C.
AU  - Broderick, J. P.
AU  - Libman, R.
AU  - Levine, S. R.
AU  - Brott, T.
DO  - 10.1212/WNL.55.7.952
PY  - 2000
TI  - Predicting prognosis after stroke: A placebo group analysis from the National Institute of Neurological Disorders and Stroke rt-PA stroke trial
T2  - Neurology
ER  -
TY  - JOUR
AB  - Background and Purpose - Intracerebral hemorrhage (ICH) constitutes 10% to 15% of all strokes and remains without a treatment of proven benefit. Despite several existing outcome prediction models for ICH, there is no standard clinical grading scale for ICH analogous to those for traumatic brain injury, subarachnoid hemorrhage, or ischemic stroke. Methods - Records of all patients with acute ICH presenting to the University of California, San Francisco during 1997-1998 were reviewed. Independent predictors of 30-day mortality were identified by logistic regression. A risk stratification scale (the ICH Score) was developed with weighting of independent predictors based on strength of association. Results - Factors independently associated with 30-day mortality were Glasgow Coma Scale score (P<0.001), age ≥80 years (P=0.001), infratentorial origin of ICH (P=0.03), ICH volume (P=0.047), and presence of intraventricular hemorrhage (P=0.052). The ICH Score was the sum of individual points assigned as follows: GCS score 3 to 4 (=2 points), 5 to 12 (=1), 13 to 15 (=0); age ≥80 years yes (=1), no (=0); infratentorial origin yes (=1), no (=0); ICH volume ≥30 cm3 (= 1), <30 cm3 (=0); and intraventricular hemorrhage yes (= 1), no (=0). All 26 patients with an ICH Score of 0 survived, and all 6 patients with an ICH Score of 5 died. Thirty-day mortality increased steadily with ICH Score (P<0.005). Conclusions - The ICH Score is a simple clinical grading scale that allows risk stratification on presentation with ICH. The use of a scale such as the ICH Score could improve standardization of clinical treatment protocols and clinical research studies in ICH.
AU  - Hemphill, J. Claude
AU  - Bonovich, David C.
AU  - Besmertis, Lavrentios
AU  - Manley, Geoffrey T.
AU  - Johnston, S. Claiborne
DO  - 10.1161/01.str.32.4.891
KW  - Intracerebral hemorrhage
KW  - Medical management
KW  - Outcome
KW  - Prognosis
KW  - Surgery
PY  - 2001
TI  - The ICH score: A simple, reliable grading scale for intracerebral hemorrhage
T2  - Stroke
ER  -
TY  - JOUR
AB  - Aim To clarify the features of stroke mimics. Methods We retrospectively investigated stroke mimic cases among the suspected stroke cases examined at our emergency department, over the past 9 years, during the tissue-type plasminogen activator treatment time window. Results Of 1,557 suspected acute stroke cases examined at the emergency department, 137 (8.8%) were stroke mimics. The most common causes were symptomatic epilepsy (28 cases, 20.4%), neuropathy-like symptoms (21 cases, 15.3%), and hypoglycemia (15 cases, 10.9%). Outcomes were survival to hospital discharge for 91.2% and death for 8.8% of the cases. Clinical results were significantly different between stroke mimics and the stroke group for low systolic blood pressure, low National Institutes of Health Stroke Scale score on initial treatment, history of diabetes, and no history of arrhythmia. On multivariate analysis, distinguishing factors for stroke mimics include systolic blood pressure ≤ 140 mmHg, National Institutes of Health Stroke Scale score ≤ 5 points, history of diabetes, and no history of arrhythmia. Conclusions Frequency of stroke mimics in cases of acute stroke suspected cases is 8.8%, and the most common cause is epilepsy. In order to distinguish stroke mimics, it is useful to understand common diseases presenting as stroke mimics and evaluate clinical features different from stroke by medical interview or nerve examination.
AU  - Okano, Yuichi
AU  - Ishimatsu, Kazuaki
AU  - Kato, Yoichi
AU  - Yamaga, Junichi
AU  - Kuwahara, Ken
AU  - Okumoto, Katsuki
AU  - Wada, Kuniyasu
DO  - 10.1002/ams2.338
PY  - 2018
TI  - Clinical features of stroke mimics in the emergency department
T2  - Acute Medicine & Surgery
ER  -
TY  - JOUR
AB  - Ischaemic stroke is a treatable medical emergency. In an era of time-dependent reperfusion techniques, it is crucial that an accurate and prompt diagnosis is made. Approximately 30% of patients admitted to hyperacute stroke units are subsequently found not to have a fi nal diagnosis of acute stroke although some of these patients do have incidental or previously symptomatic cerebrovascular disease. These patients do not benefi t from thrombolysis and may require the input of other specialists or treatments. Meanwhile, a proportion of patients with acute stroke have unusual presentations and are sometimes initially admitted to general medical admissions units prior to accessing stroke unit care. It is important that atypical presentations of stroke are recognised so that patients are not denied the benefi ts of stroke unit care and secondary prevention. This article describes some characteristics of common stroke mimics and chameleons, considers how to avoid diagnostic mistakes and discusses the contributory role of imaging.
AU  - Anathhanam, Sujo
AU  - Hassan, Ahamad
DO  - 10.7861/clinmedicine.17-2-156
PY  - 2017
TI  - Mimics and chameleons in stroke
T2  - Clinical Medicine, Journal of the Royal College of Physicians of London
ER  -
TY  - JOUR
AB  - Diagnosing stroke is not always straightforward. Stroke mimics such as Todd's paresis or hemiplegic migraine account for between a fifth and a quarter of suspected strokes (depending on the setting in which they are assessed). Stroke chameleons can arise when the tempo of symptom onset is not apoplectic or if the loss of function is not clearly consistent with a deficit within an arterial territory. Thrombolysis and secondary prevention have much to offer patients with stroke chameleons, though those with stroke mimics may be harmed by these treatments and have more to gain from other therapies.
AU  - Fernandes, Peter M.
AU  - Whiteley, William N.
AU  - Hart, Simon R.
AU  - Al-Shahi Salman, Rustam
DO  - 10.1136/practneurol-2012-000465
PY  - 2013
TI  - Strokes: Mimics and chameleons
T2  - Practical Neurology
ER  -
TY  - GEN
AB  - Purpose of reviewA stroke mimic is a situation in which a diagnosis of stroke at admission is not confirmed, and a stroke chameleon is a situation in which a stroke is revealed by clinical symptoms that are not usual in stroke. The objective of this review is to identify the most frequent clinical situations in which stroke mimics and chameleons are encountered and consequences for the patient.Recent findingsThe safety profile of intravenous thrombolysis (IVT) in patients who have stroke mimics is excellent, and intracranial hemorrhages are rare. Modern neuroimaging techniques help identifying most mimics. For stroke chameleons the role of imaging may be less important, especially when the clinical presentation is not suggestive of a brain disorder that request immediate neuroimaging. Education of health providers to identify such situations is crucial.SummaryStroke mimics account for up to 25% of admissions for probable strokes. The proportion of patients with stroke mimics decreases with use of MRI at baseline. Mimics cannot always be ruled out in emergency. The problem with mimics is that stroke facilities are not properly used, and patients may receive IVT. However, thrombolysis is usually well tolerated in mimics and we should not spend much time in all patients to improve diagnostic accuracy, knowing that the time lost is harmful in all patients, and will only prevent treating one mimic out of 100 patients. The problem with chameleons is more serious, because patients are not identified, and are not properly treated.
AU  - Moulin, Solène
AU  - Leys, Didier
DO  - 10.1097/WCO.0000000000000620
KW  - misdiagnosis
KW  - stroke
KW  - stroke chameleon
KW  - stroke mimic
PY  - 2019
TI  - Stroke mimics and chameleons
T2  - Current Opinion in Neurology
ER  -
TY  - JOUR
AB  - Patients with suspected stroke require urgent evaluation in order to identify those who may be eligible for time-sensitive therapies. A focused and systematic approach to diagnosis improves the likelihood of identifying patients with probable ischemic stroke and minimizes the chances of exposing patients with alternate diagnoses to potentially harmful treatment. This chapter emphasizes the historical, examination, and neuroimaging findings useful in the rapid evaluation and diagnosis of patients with suspected ischemic stroke. Other entities that may present with strokelike symptoms will also be discussed. 2008, © American Academy of Neurology.
AU  - Barrett, Kevin M.
AU  - Levine, Joshua M.
AU  - Johnston, Karen C.
DO  - 10.1212/01.CON.0000275638.07451.ae
PY  - 2008
TI  - Diagnosis of stroke and stroke mimics in the emergency setting
T2  - CONTINUUM Lifelong Learning in Neurology
ER  -
TY  - JOUR
AB  - Background: Although the use of magnetic resonance imaging (MRI) for the diagnosis of acute stroke is increasing, this method has not proved more effective than computed tomography (CT) in the emergency setting. We aimed to prospectively compare CT and MRI for emergency diagnosis of acute stroke. Methods: We did a single-centre, prospective, blind comparison of non-contrast CT and MRI (with diffusion-weighted and susceptibility weighted images) in a consecutive series of patients referred for emergency assessment of suspected acute stroke. Scans were independently interpreted by four experts, who were unaware of clinical information, MRI-CT pairings, and follow-up imaging. Results: 356 patients, 217 of whom had a final clinical diagnosis of acute stroke, were assessed. MRI detected acute stroke (ischaemic or haemorrhagic), acute ischaemic stroke, and chronic haemorrhage more frequently than did CT (p<0·0001, for all comparisons). MRI was similar to CT for the detection of acute intracranial haemorrhage. MRI detected acute ischaemic stroke in 164 of 356 patients (46%; 95% CI 41-51%), compared with CT in 35 of 356 patients (10%; 7-14%). In the subset of patients scanned within 3 h of symptom onset, MRI detected acute ischaemic stroke in 41 of 90 patients (46%; 35-56%); CT in 6 of 90 (7%; 3-14%). Relative to the final clinical diagnosis, MRI had a sensitivity of 83% (181 of 217; 78-88%) and CT of 26% (56 of 217; 20-32%) for the diagnosis of any acute stroke. Interpretation: MRI is better than CT for detection of acute ischaemia, and can detect acute and chronic haemorrhage; therefore it should be the preferred test for accurate diagnosis of patients with suspected acute stroke. Because our patient sample encompassed the range of disease that is likely to be encountered in emergency cases of suspected stroke, our results are directly applicable to clinical practice. © 2007 Elsevier Ltd. All rights reserved.
AU  - Chalela, Julio A.
AU  - Kidwell, Chelsea S.
AU  - Nentwich, Lauren M.
AU  - Luby, Marie
AU  - Butman, John A.
AU  - Demchuk, Andrew M.
AU  - Hill, Michael D.
AU  - Patronas, Nicholas
AU  - Latour, Lawrence
AU  - Warach, Steven
DO  - 10.1016/S0140-6736(07)60151-2
PY  - 2007
TI  - Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison
T2  - Lancet
ER  -
TY  - JOUR
AB  - Imaging plays a central role for intravenous and intra-arterial arterial ischemic stroke treatment patient selection. Computed tomography (CT) / CT angiography or magnetic resonance (MR) / MR angiography imaging are used to exclude stroke mimics and haemorrhage, to determine the cause and mechanism of stroke, to define the extension of brain infarct and to identify the arterial occlusion. Imaging may identify the patients that will be benefit more from revascularization therapies independently of the conventional therapeutic time window allowing individualized treatment decisions and improving individual patient outcome. Multiparametric CT/MR imaging may be used to identify the extension of potential viable brain tissue (penumbra) and of irreversible brain lesion (core) using CT perfusion and/or diffusion weighed and perfusion weighted MR imaging. The status of the arterial collateral circulation and the type and extension of the clot may be assessed by imaging. The accuracy and the clinical significance for treatment and patient clinical outcome of different imaging techniques are reviewed.
AU  - Vilela, Pedro
AU  - Rowley, Howard A.
DO  - 10.1016/j.ejrad.2017.08.014
KW  - Acute ischemic stroke
KW  - CT angiography
KW  - CT perfusion
KW  - Collateral circulation
KW  - Core
KW  - MR angiography
KW  - MR perfusion
KW  - Penumbra
PY  - 2017
TI  - Brain ischemia: CT and MRI techniques in acute ischemic stroke
T2  - European Journal of Radiology
ER  -
TY  - JOUR
AB  - Assessment of ischemic stroke lesions on computed tomography (CT) or MRI using the Alberta Stroke Program Early CT Score (ASPECTS) is widely used to guide acute stroke treatment. We aimed to review the current evidence on ASPECTS. Originally, the score was developed for standardized lesion assessment on non-contrast CT (NCCT). Early studies described ASPECTS as a predictor of functional outcome and symptomatic intracranial hemorrhage after iv-thrombolysis with a threshold of ≤7 suggested to identify patients at high risk. Following studies rather pointed toward a linear relationship between ASPECTS and functional outcome. ASPECTS has also been applied to assess perfusion CT and diffusion-weighted MRI (DWI). Cerebral blood volume ASPECTS proved to be the best predictor of outcome, outperforming NCCT-ASPECTS in some studies. For DWI-ASPECTS varying thresholds to identify patients at risk for poor outcome were reported. ASPECTS has been used for patient selection in three of the five groundbreaking trials proving efficacy of mechanical thrombectomy published in 2015. ASPECTS values predict functional outcome after thrombectomy. Moreover, treatment effect of thrombectomy appears to depend on ASPECTS values being smaller or not present in low ASPECTS, while patients with ASPECTS 5-10 do clearly benefit from mechanical thrombectomy. However, as patients with low ASPECTS values were excluded from recent trials data on this subgroup is limited. There are several limitations to ASPECTS addressed in a growing number of studies. The score is limited to the anterior circulation, the template is unequally weighed and correlation with lesion volume depends on lesion location. Overall ASPECTS is a useful and easily applicable tool for assessment of prognosis in acute stroke treatment and to help guide acute treatment decisions regardless whether MRI or CT is used. Patients with low ASPECTS values are unlikely to achieve good outcome. However, methodological constraints of ASPECTS have to be considered, and based on present data, a clear cutoff value to define "low ASPECTS values" cannot be given.
AU  - Schröder, Julian
AU  - Thomalla, Götz
DO  - 10.3389/fneur.2016.00245
KW  - Acute stroke treatment
KW  - Alberta Stroke Program Early CT Score
KW  - Computed tomography
KW  - Magnetic resonance imaging
KW  - Stroke
PY  - 2017
TI  - A critical review of Alberta stroke program early CT score for evaluation of acute stroke imaging
T2  - Frontiers in Neurology
ER  -
TY  - JOUR
AB  - Posterior circulation acute ischemic stroke constitutes one-fourth of all ischemic strokes and can be efficiently quantified using the posterior circulation Alberta stroke program early computed tomography score (PC-ASPECTS) through diffusion-weighted imaging. We investigated whether the PC-ASPECTS and National Institutes of Health Stroke Scale (NIHSS) facilitate functional outcome prediction among Chinese patients with posterior circulation acute ischemic stroke. Participants were selected from our prospective stroke registry from January 1, 2015, to December 31, 2016. The baseline NIHSS score was assessed on the first day of admission, and brain magnetic resonance imaging was performed within 36 h after stroke onset. Simple and multiple logistic regressions were conducted to determine stroke risk factors and the PC-ASPECTS. Receiver operating characteristics (ROC) curve analysis was performed to compare the NIHSS and PC-ASPECTS. Of 549 patients from our prospective stroke admission registry database, 125 (22.8%) had a diagnosis of posterior circulation acute ischemic stroke. The optimal cutoff for the PC-ASPECTS in predicting outcomes was 7. The odds ratios of the PC-ASPECTS (≤ 7 vs > 7) in predicting outcomes were 6.33 (p = 0.0002) and 8.49 (p = 0.0060) in the univariate and multivariate models, respectively, and 7.52 (p = 0.0041) in the aging group. On ROC curve analysis, the PC-ASPECTS demonstrated more reliability than the baseline NIHSS for predicting functional outcomes of minor posterior circulation stroke. In conclusion, both the PC-ASPECTS and NIHSS help clinicians predict functional outcomes. PC-ASPECTS > 7 is a helpful discriminator for achieving favorable functional outcome prediction in posterior circulation acute ischemic stroke.
AU  - Lin, Sheng Feng
AU  - Chen, Chin I.
AU  - Hu, Han Hwa
AU  - Bai, Chyi Huey
DO  - 10.1007/s00415-018-8746-6
KW  - Cerebral infarction
KW  - Diffusion-weighted imaging
KW  - National Institutes of Health Stroke Scale (NIHSS)
KW  - Posterior circulation
KW  - Posterior circulation Alberta stroke program early
PY  - 2018
TI  - Predicting functional outcomes of posterior circulation acute ischemic stroke in first 36 h of stroke onset
T2  - Journal of Neurology
ER  -
TY  - JOUR
AB  - BACKGROUND Thrombolytic therapy for acute ischemic stroke has been approached cautiously because there were high rates of intracerebral hemorrhage in early clinical trials. We performed a randomized, double-blind trial of intravenous recombinant tissue plasminogen activator (t-PA) for ischemic stroke after recent pilot studies suggested that t-PA was beneficial when treatment was begun within three hours of the onset of stroke. METHODS The trial had two parts. Part 1 (in which 291 patients were enrolled) tested whether t-PA had clinical activity, as indicated by an improvement of 4 points over base-line values in the score of the National Institutes of Health stroke scale (NIHSS) or the resolution of the neurologic deficit within 24 hours of the onset of stroke. Part 2 (in which 333 patients were enrolled) used a global test statistic to assess clinical outcome at three months, according to scores on the Barthel index, modified Rankin scale, Glasgow outcome scale, and NIHSS: RESULTS In part 1, there was no significant difference between the group given t-PA and that given placebo in the percentages of patients with neurologic improvement at 24 hours, although a benefit was observed for the t-PA group at three months for all four outcome measures. In part 2, the long-term clinical benefit of t-PA predicted by the results of part 1 was confirmed (global odds ratio for a favorable outcome, 1.7; 95 percent confidence interval, 1.2 to 2.6). As compared with patients given placebo, patients treated with t-PA were at least 30 percent more likely to have minimal or no disability at three months on the assessment scales. Symptomatic intracerebral hemorrhage within 36 hours after the onset of stroke occurred in 6.4 percent of patients given t-PA but only 0.6 percent of patients given placebo (P < 0.001). Mortality at three months was 17 percent in the t-PA group and 21 percent in the placebo group (P = 0.30). CONCLUSIONS Despite an increased incidence of symptomatic intracerebral hemorrhage, treatment with intravenous t-PA within three hours of the onset of ischemic stroke improved clinical outcome at three months.
AU  - &NA;
DO  - 10.1097/00008506-199604000-00018
PY  - 1996
TI  - Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke t-PA Stroke Study Group
T2  - Journal of Neurosurgical Anesthesiology
ER  -
TY  - JOUR
AB  - Background: Early administration of intravenous recombinant tissue plasminogen activator (rt-PA) after ischaemic stroke improves outcome. Previous analysis of combined data from individual patients suggested potential benefit beyond 3 h from stroke onset. We re-examined the effect of time to treatment with intravenous rt-PA (alteplase) on therapeutic benefit and clinical risk by adding recent trial data to the analysis. Methods: We added data from ECASS III (821 patients) and EPITHET (100 patients) to a pool of common data elements from six other trials of alteplase for acute stroke (2775 patients). We used multivariate logistic regression to assess the relation of stroke onset to start of treatment (OTT) with treatment on favourable 3-month outcome (defined as modified Rankin score 0-1), mortality, and occurrence and outcome of clinically relevant parenchymal haemorrhage. The presence of an arterial occlusion was inferred from the patient's symptoms and absence of haemorrhage or other causes of ischaemic stroke. Vascular imaging was not a requirement in the trials. All patients with confirmed OTT within 360 min were included in the analysis. Findings: Treatment was started within 360 min of stroke onset in 3670 patients randomly allocated to alteplase (n=1850) or to placebo (n=1820). Odds of a favourable 3-month outcome increased as OTT decreased (p=0·0269) and no benefit of alteplase treatment was seen after around 270 min. Adjusted odds of a favourable 3-month outcome were 2·55 (95% CI 1·44-4·52) for 0-90 min, 1·64 (1·12-2·40) for 91-180 min, 1·34 (1·06-1·68) for 181-270 min, and 1·22 (0·92-1·61) for 271-360 min in favour of the alteplase group. Large parenchymal haemorrhage was seen in 96 (5·2%) of 1850 patients assigned to alteplase and 18 (1·0%) of 1820 controls, with no clear relation to OTT (p=0·4140). Adjusted odds of mortality increased with OTT (p=0·0444) and were 0·78 (0·41-1·48) for 0-90 min, 1·13 (0·70-1·82) for 91-180 min, 1·22 (0·87-1·71) for 181-270 min, and 1·49 (1·00-2·21) for 271-360 min. Interpretation: Patients with ischaemic stroke selected by clinical symptoms and CT benefit from intravenous alteplase when treated up to 4·5 h. To increase benefit to a maximum, every effort should be taken to shorten delay in initiation of treatment. Beyond 4·5 h, risk might outweigh benefit. Funding: None. © 2010 Elsevier Ltd. All rights reserved.
AU  - Lees, Kennedy R.
AU  - Bluhmki, Erich
AU  - von Kummer, Rüdiger
AU  - Brott, Thomas G.
AU  - Toni, Danilo
AU  - Grotta, James C.
AU  - Albers, Gregory W.
AU  - Kaste, Markku
AU  - Marler, John R.
AU  - Hamilton, Scott A.
AU  - Tilley, Barbara C.
AU  - Davis, Stephen M.
AU  - Donnan, Geoffrey A.
AU  - Hacke, Werner
DO  - 10.1016/S0140-6736(10)60491-6
PY  - 2010
TI  - Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials
T2  - The Lancet
ER  -
TY  - JOUR
AB  - BACKGROUND: Intravenous thrombolysis with alteplase is the only approved treatment for acute ischemic stroke, but its efficacy and safety when administered more than 3 hours after the onset of symptoms have not been established. We tested the efficacy and safety of alteplase administered between 3 and 4.5 hours after the onset of a stroke. METHODS: After exclusion of patients with a brain hemorrhage or major infarction, as detected on a computed tomographic scan, we randomly assigned patients with acute ischemic stroke in a 1:1 double-blind fashion to receive treatment with intravenous alteplase (0.9 mg per kilogram of body weight) or placebo. The primary end point was disability at 90 days, dichotomized as a favorable outcome (a score of 0 or 1 on the modified Rankin scale, which has a range of 0 to 6, with 0 indicating no symptoms at all and 6 indicating death) or an unfavorable outcome (a score of 2 to 6 on the modified Rankin scale). The secondary end point was a global outcome analysis of four neurologic and disability scores combined. Safety end points included death, symptomatic intracranial hemorrhage, and other serious adverse events. RESULTS: We enrolled a total of 821 patients in the study and randomly assigned 418 to the alteplase group and 403 to the placebo group. The median time for the administration of alteplase was 3 hours 59 minutes. More patients had a favorable outcome with alteplase than with placebo (52.4% vs. 45.2%; odds ratio, 1.34; 95% confidence interval [CI], 1.02 to 1.76; P=0.04). In the global analysis, the outcome was also improved with alteplase as compared with placebo (odds ratio, 1.28; 95% CI, 1.00 to 1.65; P<0.05). The incidence of intracranial hemorrhage was higher with alteplase than with placebo (for any intracranial hemorrhage, 27.0% vs. 17.6%; P=0.001; for symptomatic intracranial hemorrhage, 2.4% vs. 0.2%; P=0.008). Mortality did not differ significantly between the alteplase and placebo groups (7.7% and 8.4%, respectively; P=0.68). There was no significant difference in the rate of other serious adverse events. CONCLUSIONS: As compared with placebo, intravenous alteplase administered between 3 and 4.5 hours after the onset of symptoms significantly improved clinical outcomes in patients with acute ischemic stroke; alteplase was more frequently associated with symptomatic intracranial hemorrhage. (ClinicalTrials.gov number, NCT00153036.) Copyright © 2008 Massachusetts Medical Society. All rights reserved.
AU  - Hacke, Werner
AU  - Kaste, Markku
AU  - Bluhmki, Erich
AU  - Brozman, Miroslav
AU  - Dávalos, Antoni
AU  - Guidetti, Donata
AU  - Larrue, Vincent
AU  - Lees, Kennedy R.
AU  - Medeghri, Zakaria
AU  - Machnig, Thomas
AU  - Schneider, Dietmar
AU  - Von Kummer, Rüdiger
AU  - Wahlgren, Nils
AU  - Toni, Danilo
DO  - 10.1056/NEJMoa0804656
PY  - 2008
TI  - Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke
T2  - New England Journal of Medicine
ER  -
TY  - JOUR
AB  - Background and Purpose-Intravenous thrombolysis for acute ischemic stroke is beneficial within 4.5 hours of symptom onset, but the effect rapidly decreases over time, necessitating quick diagnostic in-hospital work-up. Initial time strain occasionally results in treatment of patients with an alternate diagnosis (stroke mimics). We investigated whether intravenous thrombolysis is safe in these patients. Methods-In this multicenter observational cohort study containing 5581 consecutive patients treated with intravenous thrombolysis, we determined the frequency and the clinical characteristics of stroke mimics. For safety, we compared the symptomatic intracranial hemorrhage (European Cooperative Acute Stroke Study II [ECASS-II] definition) rate of stroke mimics with ischemic strokes. Results-One hundred stroke mimics were identified, resulting in a frequency of 1.8% (95% confidence interval, 1.5-2.2). Patients with a stroke mimic were younger, more often female, and had fewer risk factors except smoking and previous stroke or transient ischemic attack. The symptomatic intracranial hemorrhage rate in stroke mimics was 1.0% (95% confidence interval, 0.0-5.0) compared with 7.9% (95% confidence interval, 7.2-8.7) in ischemic strokes. Conclusions-In experienced stroke centers, among patients treated with intravenous thrombolysis, only a few had a final diagnosis other than stroke. The complication rate in these stroke mimics was low. © 2013 American Heart Association, Inc.
AU  - Zinkstok, Sanne M.
AU  - Engelter, Stefan T.
AU  - Gensicke, Henrik
AU  - Lyrer, Philippe A.
AU  - Ringleb, Peter A.
AU  - Artto, Ville
AU  - Putaala, Jukka
AU  - Haapaniemi, Elena
AU  - Tatlisumak, Turgut
AU  - Chen, Yaohua
AU  - Leys, Didier
AU  - Sarikaya, Hakan
AU  - Michel, P.
AU  - Odier, Céline
AU  - Berrouschot, Jörg
AU  - Arnold, Marcel
AU  - Heldner, Mirjam R.
AU  - Zini, Andrea
AU  - Fioravanti, Valentina
AU  - Padjen, Visnja
AU  - Beslac-Bumbasirevic, Ljiljana
AU  - Pezzini, Alessandro
AU  - Roos, Yvo B.
AU  - Nederkoorn, Paul J.
DO  - 10.1161/STROKEAHA.111.000126
KW  - Safety
KW  - Stroke
KW  - Stroke mimics
KW  - Thrombolysis
PY  - 2013
TI  - Safety of thrombolysis in stroke mimics: Results from a multicenter cohort study
T2  - Stroke
ER  -
TY  - JOUR
AB  - Background: Stroke mimics are frequently treated with thrombolysis in clinical practice and thrombolytic trials. Although alteplase in stroke mimics has proven to be safe, safety of tenecteplase in stroke mimics has not been assessed in an ischemic stroke study setting. We aimed to assess clinical characteristics and safety of stroke mimics treated with thrombolysis in the Norwegian Tenecteplase Stroke Trial. We also aimed to identify possible predictors of stroke mimics as compared to patients with acute cerebral ischemia. Methods: Norwegian Tenecteplase Stroke Trial was a phase-3 trial investigating safety and efficacy of tenecteplase vs. alteplase in patients with suspected acute cerebral ischemia. Two groups were defined based on diagnose at discharge: patients with a different diagnose than ischemic stroke or transient ischemic attack (stroke mimics group) and patients diagnosed with ischemic stroke or transient ischemic attack (acute cerebral ischemia group). Logistic regression analyses were performed with stroke mimics vs. acute cerebral ischemia as dependent variable to identify predictors of stroke mimics. Results: Of 1091 randomized patients, 181 (16.6%) were stroke mimics. Migraine (22.2%) and peripheral vertigo (11.4%) were the two most frequent stroke mimic-diagnoses. There was no symptomatic intracerebral hemorrhage in the stroke mimics group. Stroke mimics were independently associated with age ≤60 years (OR 2.75, p < 0.001), female sex (OR 1.48, p = 0.026), no history of myocardial infarction (OR 2.03, p = 0.045), systolic BP ≤ 150 mmHg (OR 2.33, p < 0.001), NIHSS ≤ 6 points (OR 1.83, p = 0.011), sensory loss (OR 1.55, p = 0.015), and no facial paresis (OR 2.41, p < 0.001) on admission. Conclusion: Thrombolysis with tenecteplase seems to be as safe as with alteplase in stroke mimics. Predictors were identified for stroke mimics which may contribute to differentiate stroke mimics from acute cerebral ischemia in future stroke trials.
AU  - Kvistad, Christopher Elnan
AU  - Novotny, Vojtech
AU  - Næss, Halvor
AU  - Hagberg, Guri
AU  - Ihle-Hansen, Hege
AU  - Waje-Andreassen, Ulrike
AU  - Thomassen, Lars
AU  - Logallo, Nicola
DO  - 10.1177/1747493018790015
KW  - Acute ischemic stroke
KW  - alteplase
KW  - intravenous thrombolysis
KW  - stroke mimics
KW  - tenecteplase
PY  - 2019
TI  - Safety and predictors of stroke mimics in The Norwegian Tenecteplase Stroke Trial (NOR-TEST)
T2  - International Journal of Stroke
ER  -