Jamaican Susumber Berry Poisoning Mimicking Acute Stroke.

BACKGROUND: Stroke mimics are non-vascular conditions that present with acute focal neurological deficits, simulating an acute ischemic stroke. Susumber berry (SB) toxicity is a rare cause of stroke mimic with limited case reports available in the literature. OBJECTIVES: We report four new cases of SB toxicity presenting as stroke mimic, and we performed a systematic review. METHODS: MEDLINE/EMBASE/WoS were searched for "susumber berries," "susumber," or "solanum torvum." RESULTS: 531 abstracts were screened after removal of duplicates; 5 articles and 2 conference abstracts were selected describing 13 patients. A total of 17 patients who ingested SB and became ill were identified, including our 4 patients. All but one presented with acute neurologic manifestation; 16 (94%) presented with dysarthria, 16 (94%) with unstable gait, 8 (47%) with nystagmus/gaze deviation, 10 (59%) with blurry vision, and 5 (29%) with autonomic symptoms. Six (35%) required ICU admission, and 3 (18%) were intubated. Fourteen (82%) had a rapid complete recovery, and 3 were hospitalized up to 1 month. CONCLUSIONS: SB toxicity can cause neurological symptoms that mimic an acute stroke typically with a posterior circulation symptom complex. Altered SB toxins (from post-harvest stressors or temperature changes) might stimulate muscarinic/nicotinic cholinergic receptors or inhibit acetylcholinesterase, causing gastrointestinal, neurological, and autonomic symptoms. In cases of multiple patients presenting simultaneously to the ED with stroke-like symptoms or when stroke-like symptoms fail to localize, a toxicological etiology (such as SB toxicity) should be considered.

Imaging of Suspected Stroke in Children, From the AJR Special Series on Emergency Radiology.

Pediatric stroke encompasses different causes, clinical presentations, and associated conditions across ages. Although it is relatively uncommon, pediatric stroke presents with poor short- and long-term outcomes in many cases. Because of a wide range of overlapping presenting symptoms between pediatric stroke and other more common conditions, such as migraine and seizures, stroke diagnosis can be challenging or delayed in children. When combined with a comprehensive medical history and physical examination, neuroimaging plays a crucial role in diagnosing stroke and differentiating stroke mimics. This review highlights the current neuroimaging workup for diagnosing pediatric stroke in the emergency department, describes advantages and disadvantages of different imaging modalities, highlights disorders that predispose children to infarct or hemorrhage, and presents an overview of stroke mimics. Key differences in the initial approach to suspected stroke between children and adults are also discussed.

Rural versus metropolitan comparison of processes of care in the community-based management of TIA and minor stroke in Australia (an analysis from the INSIST study).

OBJECTIVES: To compare processes of care and clinical outcomes of community-based management of TIAs and minor strokes (TIAMS) between rural and metropolitan Australia. DESIGN: Inception cohort study between 2012 and 2016 with 12-month follow-up after index event (sub-study of INSIST). SETTING: Hunter and Manning valley regions of New South Wales, within the referral territory of the John Hunter Hospital Acute Neurovascular Clinic (JHHANC). PARTICIPANTS: Consecutive patients of 16 participating general practices, presenting with possible TIAMS to either primary or secondary care. MAIN OUTCOME MEASURES: Processes of care (referrals, key management processes, time-based metrics) and clinical outcomes. RESULTS: Of 613 participants with possible TIAMS who completed the baseline interview, 298 were adjudicated as having TIAMS (119 from rural, 179 from metropolitan). Mean age was 72.3 years (SD, 10.7) and 127 (43%) were women. Rural participants were more likely to be managed solely by a general practitioner (GP) than metropolitan participants (34% v 20%) and less likely to be referred to a JHHANC specialist (13% v 38%) or have brain magnetic resonance imaging (MRI) [24% v 51%]. Those rural participants who were referred, also waited longer (both p < 0.001). Recurrent stroke, myocardial infarction and death at 12 months were not significantly different between rural and metropolitan participants. CONCLUSIONS: Although TIAMS prognosis in rural settings where solely GP care is common is very good, the processes of care in such areas are inferior to metropolitan. This suggests there is further scope to support rural GPs to optimise care of TIAMS patients.

Acute stroke-like deficits associated with nonketotic hyperglycemic hyperosmolar state: an illustrative case and systematic review of literature.

INTRODUCTION: Nonketotic hyperglycemic hyperosmolar state (NKHHS) is associated with a wide spectrum of neurological syndromes including acute stroke-like deficits. Clinical features and etiology have not been established yet. METHODS: Here we provide a case illustration and systematic review on non-epileptic acute neurological deficits in NKHSS. The systematic literature search followed PRISMA guidelines and a predefined protocol, including cases of NKHSS with acute stroke-like presentation. RESULTS: The database search yielded 18 cases. Hemianopia was the most common clinical presentation (73%), followed by partial or total anterior circulation syndrome (26%). Patients with symptoms of acute anterior circulation infarct were significantly older (69.5 ± 5.1 vs. 52.2 ± 13.9 years; p = 0.03) and showed higher mean glucose levels at the admission vs. those with hemianopia (674.8 ± 197.2 vs. 529.4 ± 190.8 mg/dL; p = 0.16). Brain MRI was performed in 89% of patients, resulting abnormal in 71% of them, especially hemianopic (91%). Subcortical hypointensities in T2-FLAIR MR sequences were present in all the analyzed cases. Cortical DWI hyperintensities were also common (64%). EEG showed diffuse or focal slow wave activity in 68% of patients, especially with visual hallucinations (85%). Neurological symptoms completely resolved in 78% of patients within 6 (IQR 3-10) days, following aggressive treatment and glucose normalization. CONCLUSIONS: Our results suggest neuronal dysfunction on a metabolic basis as the leading cause of acute neurological deficits in NKHHS. Despite the generally favorable prognosis, prompt identification and aggressive treatment are crucial to avoid irreversible damage. Larger cohort studies are needed to confirm our findings.

Neurologic toxicity of carbamazepine in treatment of trigeminal neuralgia.

Carbamazepine is a medication used to treat a variety of neurological and psychiatric conditions including seizure disorders, neuropathic pain syndromes, and bipolar disorder. Unfortunately, its pharmacokinetics and side effect profile may lead to significant toxicities due to its sodium channel blockade. In 2019, there were over 1500 cases of isolated carbamazepine toxicity reported to poison centers across the United States. Carbamazepine toxicity may result in vague neurological symptoms in milder cases, but in severe toxicity, it can cause cardiovascular instability, intractable seizures, and coma. In this article, we describe a case of a 40-year-old female who presented to a local emergency department with focal neurological deficits after repeated supratherapeutic dosing of carbamazepine.. This case highlights a key cerebrovascular accident mimic that emergency physicians should consider from acute toxicity that can be seen with carbamazepine in a patient who was taking the medication as prescribed.

Stroke-mimicking unilateral hypokalemic paralysis and literature review.

Unilateral paralysis is an alarming symptom with broad differential diagnoses, including stroke, Todd's paralysis, myelopathy, and peripheral neuropathy. Hypokalemic paralysis (HP), a neuromuscular disorder associated with muscle dysfunction, is caused by hypokalemia and manifests as symmetric proximal extremity muscle weakness. Unilateral paralysis has rarely been reported in the literature. Once hypokalemia is corrected, HP is usually reversible. Delayed diagnosis and treatment may result in fatal consequences. Here, we report an atypical case of unilateral weakness along with a review of the literature on unilateral HP.

Thrombotic microangiopathy presenting with stroke-like symptoms.

Thrombotic microangiopathies are a diverse group of clinical syndromes characterized by microangiographic hemolytic anemia, thrombocytopenia, and organ dysfunction. We report a unique case of thrombotic microangiopathy in an adult caused by vitamin B12 deficiency that presented with stroke-like symptoms.

Hypoglycemic hemiparesis as stroke mimic with transient splenial lesion and internal capsule involvement: A reversible clinico-radiological concurrence.

Hypoglycemia presents with a spectrum of neurological manifestations ranging from lightheadedness to confusion and coma. We report here the case of a 61-year-old woman with right hemiparesis presenting within the window period for stroke thrombolysis. MRI brain showed diffusion restriction in posterior limb of left internal capsule and splenium. Patient had documented hypoglycemia of 38 mg/dL. Patient's hemiparesis resolved after glucose correction, and radiological findings completely resolved after 10 days. We present this case to highlight the rare radiological finding of simultaneous internal capsule and splenium involvement in hypoglycemic hemiparesis and the importance to rule out stroke mimics to avoid unwanted thrombolysis.

Neuroimages and Neuropathology of a Stroke-Like Cerebral Lymphomatoid Granulomatosis.

A 70-year-old man presented to the Emergency Department reporting the acute onset of non-fluent aphasia, hyposthenia, and hemi-anesthesia of the right body. Brain computerized tomography revealed a subcortical hypodense lesion in the middle cerebral artery territory. Neck ultrasounds of internal and external carotid arteries and of the vertebral arteries showed a focal moderate stenosis of the left internal carotid artery due to a soft atheromasic plaque. These findings that were initially consistent with a diagnosis of an ischemic stroke were not confirmed by magnetic resonance (MR). The latter showed an hyperintense lesion on FLAIR and T2-weighted sequences located in the left centrum semiovale, corona radiata, and thalamus, with a well-defined regular rim and a mild compressive effect on the lateral ventricle, with diffusivity restriction but without ADC reduction and with a punctate and serpiginous gadolinium enhancement on T1 sequences (Figure 1). Within the first day of observation, the patient started complaining progressive mental deterioration, in absence of any other possible causes, and a total body CT scan excluded any other organ involvement. Patient was then referred to the neurosurgeon in order to perform a brain biopsy. The neuropathology was compatible with the diagnosis of cerebral lymphomatoid granulomatosis (LG) (Figure 1).

Squamous Cell Carcinoma of the Neck: An Unlikely Stroke Mimic.

BACKGROUND: Stroke mimics are noncerebrovascular conditions that present with classical stroke symptoms. They account for up to 30% of stroke presentations in the emergency department (ED). Emergency physicians are faced with a diagnostic dilemma-rapid treatment of stroke, a leading cause or mortality and morbidity in the United States, or ruling out the ever-growing list of conditions that mimic strokes. CASE REPORT: An 87-year-old man with a 60-year smoking history, chronic obstructive pulmonary disease, and extensive cardiovascular disease history presented to the ED with a chief symptom of new onset right-arm weakness. Computed tomography (CT) excluded hemorrhage and lesions, and additional CT angiography imaging revealed a large mass compressing the right subclavian artery. Given the initial workup, mass effect on the right brachial plexus better explained the patient's symptoms. Two weeks later, a CT scan of the chest, abdomen, and pelvis revealed masses on the pubic ramus, iliac bone, and several vertebral bodies. Biopsy of the rib mass revealed squamous cell carcinoma. The patient was diagnosed with bone metastasis of unknown origin and started on radiation therapy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Even in fast-paced settings, clinicians must maintain a high level of suspicion for stroke mimics. This case illustrates the vital importance of neuroimaging in the diagnosis of stroke mimics and discusses clinical characteristics and patient risk factors that increase the likelihood of a stroke mimic diagnosis, serving as a tool for physicians facing this diagnostic dilemma.

Validation of the Telestroke Mimic Score in Mayo Clinic Population.

OBJECTIVES: Telestroke consultations enable hospital providers to administer intravenous (IV) alteplase to patients who would otherwise not receive it due to lack of an in-hospital stroke team. However, up to 30% of acute stroke patient evaluations are deemed to be stroke mimics. Mimics present a challenge with the limitations of a virtual neurological exam. The administration of IV alteplase in these patients is not without risk. With the cost and risk associated with IV alteplase, there are both ethical and practical incentives to avoid administering alteplase to a patient manifesting a stroke-mimic. Recently a retrospective analysis validated a TeleStroke Mimic Score (TM-Score) to help detect stroke mimics. We retrospectively applied this tool to Mayo Clinic Stroke Telemedicine for Arizona Rural Residents (STARR) telestroke database to provide external validation in an independent study population. MATERIALS AND METHODS: We analyzed 339 patients in the STARR database for validation of the TM-Score, which was applied retrospectively to determine whether it predicted stroke-mimic, using data available during each patient's telestroke consult. We assessed the TM-Score's performance with a receiver-operating characteristic (ROC) curve. A scatter plot of the data was assembled to demonstrate the relationship between the TM-Score and the likelihood of having a stroke mimic, and was compared to the nomogram in the original TM-Score study. RESULTS: When the TM-Score was applied to Mayo Clinic STARR validation cohort, the area under the ROC curve was 0.78, larger than that of the derivation cohort in the original study (0.75). Further analysis suggested that a TM-Score > 25 or < 10 provided a greater degree of confidence that the patient had presented with stroke or stroke mimic, respectively.  In STARR cohort, additional variables were significantly different between stroke and stroke mimic populations, including a history of sleep apnea and diabetes. CONCLUSIONS: We determined that the original TM-Score was valid when applied to Mayo Clinic STARR telestroke population.

COVID-19 Encephalitis with SARS-CoV-2 Detected in Cerebrospinal Fluid Presenting as a Stroke Mimic.

We report the case of a 35-year-old male with COVID-19 encephalitis presenting as a stroke mimic with sudden-onset expressive and receptive dysphasia, mild confusion and right arm incoordination. The patient received thrombolysis for a suspected ischaemic stroke, but later became febrile and SARS-CoV-2 was detected in cerebrospinal fluid. Electroencephalography demonstrated excess in slow waves, but neuroimaging was reported as normal. Respiratory symptoms were absent throughout and nasopharyngeal swab was negative for SARS-CoV-2. At the most recent follow-up, the patient had made a full neurological recovery. Clinicians should therefore consider testing for SARS-CoV-2 in CSF in patients who present with acute focal neurology, confusion and fever during the pandemic, even when there is no evidence of respiratory infection.

Cerebral Venous Thrombosis Mimicking Acute Ischemic Stroke in the Emergency Assessment of Thrombolysis Eligibility: Learning from a Misdiagnosed Case.

PURPOSE: Cerebral venous thrombosis (CVT) occasionally presents with acute focal neurologic signs, mimicking arterial stroke syndrome. Diagnosing CVT in the setting of thrombolysis eligibility evaluation is challenging. We reported this case to discuss the promptly recognizing CVT in the setting of thrombolysis eligibility evaluation, and review the literature of thrombolytic therapy in CVT patients. CASE REPORT: A 57-year-old man presented with acute-onset right upper extremity monoparesis, right facial palsy, and aphasia. He underwent emergent thrombolysis with recombinant tissue plasminogen activator according to American Stroke Association guidelines. Subsequently, CVT was identified on multiphase computed tomography (CT) angiography. His symptoms initially improved but subsequently deteriorated because of intracranial hemorrhage. Cryoprecipitate and tranexamic acid were immediately administered. Anticoagulation was started 24 hours after the onset of hemorrhage. His modified Rankin Scale score was 4 at 120 days after the hemorrhage. CONCLUSION: Patients with CVT have a higher risk of thrombolysis-related intracranial hemorrhage than other stroke mimics. A greater focus on noncontrast brain CT and the venous phase of CT angiography help identifying this stroke mimic before thrombolysis.

Characteristics of Perfusion Computed Tomography Imaging in Patients with Seizures Mimicking Acute Stroke.

INTRODUCTION: Seizures as acute stroke mimics are a diagnostic challenge. OBJECTIVE: The aim of the study was to characterize the perfusion patterns on perfusion computed tomography (PCT) in patients with seizures masquerading as acute stroke. METHODS: We conducted a study on patients with acute seizures as stroke mimics. The inclusion criteria for this study were patients (1) initially presenting with stroke-like symptoms but finally diagnosed to have seizures and (2) with PCT performed within 72 h of seizures. The PCT of seizure patients (n = 27) was compared with that of revascularized stroke patients (n = 20) as the control group. RESULTS: Among the 27 patients with seizures as stroke mimics, 70.4% (n = 19) showed characteristic PCT findings compared with the revascularized stroke patients, which were as follows: (1) multi-territorial cortical hyperperfusion {(73.7% [14/19] vs. 0% [0/20], p = 0.002), sensitivity of 73.7%, negative predictive value (NPV) of 80%}, (2) involvement of the ipsilateral thalamus {(57.9% [11/19] vs. 0% [0/20], p = 0.007), sensitivity of 57.9%, NPV of 71.4%}, and (3) reduced perfusion time {(84.2% [16/19] vs. 0% [0/20], p = 0.001), sensitivity of 84.2%, NPV of 87%}. These 3 findings had 100% specificity and positive predictive value in predicting patients with acute seizures in comparison with reperfused stroke patients. Older age was strongly associated with abnormal perfusion changes (p = 0.038), with a mean age of 66.8 ± 14.5 years versus 49.2 ± 27.4 years (in seizure patients with normal perfusion scan). CONCLUSIONS: PCT is a reliable tool to differentiate acute seizures from acute stroke in the emergency setting.

A predictive analytics model for differentiating between transient ischemic attacks (TIA) and its mimics.

BACKGROUND: Transient ischemic attack (TIA) is a brief episode of neurological dysfunction resulting from cerebral ischemia not associated with permanent cerebral infarction. TIA is associated with high diagnostic errors because of the subjective nature of findings and the lack of clinical and imaging biomarkers. The goal of this study was to design and evaluate a novel multinomial classification model, based on a combination of feature selection mechanisms coupled with logistic regression, to predict the likelihood of TIA, TIA mimics, and minor stroke. METHODS: We conducted our modeling on consecutive patients who were evaluated in our health system with an initial diagnosis of TIA in a 9-month period. We established the final diagnoses after the clinical evaluation by independent verification from two stroke neurologists. We used Recursive Feature Elimination (RFE) and Least Absolute Shrinkage and Selection Operator (LASSO) for prediction modeling. RESULTS: The RFE-based classifier correctly predicts 78% of the overall observations. In particular, the classifier correctly identifies 68% of the cases labeled as "TIA mimic" and 83% of the "TIA" discharge diagnosis. The LASSO classifier had an overall accuracy of 74%. Both the RFE and LASSO-based classifiers tied or outperformed the ABCD2 score and the Diagnosis of TIA (DOT) score. With respect to predicting TIA, the RFE-based classifier has 61.1% accuracy, the LASSO-based classifier has 79.5% accuracy, whereas the DOT score applied to the dataset yields an accuracy of 63.1%. CONCLUSION: The results of this pilot study indicate that a multinomial classification model, based on a combination of feature selection mechanisms coupled with logistic regression, can be used to effectively differentiate between TIA, TIA mimics, and minor stroke.

Multiple Administrations of Intravenous Thrombolytic Therapy to a Stroke Mimic.

BACKGROUND: Patients who present emergently with focal neurological deficits concerning for acute ischemic stroke can be extremely challenging to diagnose and treat. Unnecessary administration of thrombolytics to potential stroke patients whose symptoms are not caused by an acute ischemic stroke-stroke mimics-may result in patient harm, although the overall risk of hemorrhagic complications among stroke mimics is low. CASE REPORT: We present a case of a stroke mimic patient with underlying psychiatric disease who was treated with intravenous alteplase on four separate occasions in four different emergency departments in the same city. Although he did not suffer hemorrhagic complications, this case highlights the importance of rapid exchange of health information across institutions to improve diagnostic quality and safety. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Increased awareness of stroke mimics by emergency physicians may improve diagnostic safety for a subset of high-risk patients. Establishing rapid cross-institutional communication pathways that are integrated into provider's workflows to convey essential patient health information has potential to improve stroke diagnostic decision-making and thus represents an important topic for health systems research in emergency medicine.

Unknown Tetrahydrocannabinol Edible Ingestion Resulting in Acute Stroke Presentation.

BACKGROUND: Marijuana is a commonly used substance in the United States for both recreational and medicinal purposes. Detrimental health-related effects of marijuana continue to be a source of controversy. CASE REPORT: We describe a case of a woman who presented to the emergency department with acute right upper and lower extremity weakness and altered speech after accidental unknown ingestion of food containing tetrahydrocannabinol (THC). This is a unique case in that we could find no other published report of focal weakness or motor stroke symptoms occurring in the setting of THC ingestion. We will discuss in detail the patient's medical history and timeline of events leading to her presentation to the emergency department. Marijuana contains the psychoactive substance THC and is becoming more commonly used for medicinal and recreational purposes in the United States and abroad. The use of THC is associated with changes in levels of consciousness, perception, and several other physiologic processes. We hope to increase awareness through this case report of accidental THC use by a female patient that resulted in a stroke code and potentially could have led to the use of tissue plasminogen activator. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To the best of our knowledge, focal neurologic deficits associated with THC use have not been reported in the published literature. We hope that this knowledge will encourage physicians to consider THC intoxication as a cause of new onset extremity weakness.

Stroke Mimics: Experience of a Moroccan Stroke Unit.

BACKGROUND: Stroke mimic is a medical condition presenting with acute neurological deficit and simulate real stroke. The objective of this study was to evaluate the frequency and the various etiologies of stroke mimics in our center. METHODS: We retrospectively reviewed the Thrombolysis Alert registry and we studied the frequency and characteristics of patients with stroke mimic. RESULTS: Among 673 patients who were admitted to the emergency department within 4.5 hours for sudden focal neurological deficit suggestive of acute stroke, 105 patients (15.6 %) had a stroke mimic. The mean age of patients with mimics and brain strokes were 66.3 and 64.8, respectively. The mean Onset-to-door time was 136.82 minutes and the mean door-to-imaging time was 32.63 minutes in stroke mimics. Seizure (28.5%) was the most common diagnosis of stroke mimics followed by conversion disorder (25.7%). CONCLUSIONS: Stroke mimic is frequent and heterogeneous entity that can be difficult to identify. Fortunately, most previous studies show no harmful effects when using thrombolysis in a stroke mimic.

A Case of Creutzfeldt-Jakob Disease with Stroke-Like Onset.

Creutzfeldt-Jakob disease (CJD) is a prion disease characterized by rapidly progressive dementia that is often followed by behavioral disturbances, ataxia, myoclonus, and akinetic mutism. The initial symptoms of CJD reportedly vary, but the onset is usually gradual. Here, we report a case of CJD with a sudden, stroke-like onset of right hemiparesis to alert readers that CJD can mimic a stroke during its early stage.

Code Stroke Patient Referral by Emergency Medical Services During the Public COVID-19 Pandemic Lockdown.

BACKGROUND: The COVID-19 pandemic caused public lockdowns around the world. We analyzed if the public lockdown altered the referral pattern of Code Stroke patients by Emergency Medical Services (EMS) to our Comprehensive Stroke Center. METHODS: Retrospective single-center study at a Bavarian Comprehensive Stroke Center. Patients who were directly referred to our stroke unit by EMS between the 1st of January 2020 and the 19th of April 2020 were identified and number of referrals, clinical characteristics and treatment strategies were analyzed during the public lockdown and before. The public lockdown started on 21st of March and ended on 19th April 2020. RESULTS: In total 241 patients were referred to our center during the study period, i.e. 171 before and 70 during the lockdown. The absolute daily number of Code Stroke referrals and the portion of patients with stroke mimics remained stable. The portion of female stroke patients decreased (55% to 33%; p = 0.03), and stroke severity as measured by the National Institutes of Health Stroke Scale (median 3 (IQR 0-7) versus 6 (IQR 1-15.5) points; p = 0.04) increased during the lockdown. There was no difference of daily numbers of patients receiving thrombolysis and thrombectomy. CONCLUSIONS: Referral of Code Stroke patients by EMS could be maintained sufficiently despite the COVID-19 pandemic lockdown. However, patients' health care utilization of the EMS may have changed within the public lockdown. EMS remains a useful tool for Code Stroke patient referral during lockdowns, but public education about stroke is required prior to further lockdowns.