TIA and Stroke mimics -

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TIA and Stroke mimics - spells
Shelagh Coutts MD, FRCPC Assistant Professor,
Calgary Stroke Program, University of Calgary

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AIMS

• To describe some of the stroke or TIA mimics.
• To run through focal versus non focal symptoms.
• To give some helpful diagnostic pearls.
• To review what is a stroke or a TIA.
• To identify what spells you be worried about.

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The Definition of Stroke/ TIA

• A clinical syndrome characterized by the sudden
  onset of a focal neurological deficit presumed to
  be on a vascular basis.

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What is a TIA and why is it not that simple

• Diagnosis is made on history
• Dont take what you are told for granted.
• numb, dead, heavy, weak all mean different
  things to different people.
• What else could it be.

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Conditions Misdiagnosed as TIA

• Migraine aura
• Syncope, postural hypotension
• Seizure
• Vertigo
• Transient Global Amnesia
• Anxiety/Hyperventilation
• Confusion
• Unexplained fall
• Peripheral nerve palsy

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The clinical diagnosis can be hard

• Bush Health Problems? Stroke?
• Then I got a call this morning from another
  medical producer.  First thing he says is  Bush
  has had a stroke.  And it hit me, that's exactly
  what I saw.  Check Bush's mouth, where the
  spittle was coming out.  It's slightly droopy.
   It's very subtle but it's there.

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What do non neurologists think are Strokes?
Diagnosis
Seizure/post-ictal 19 Migraine
15 Functional disorder
14 Metabolic disturbance
8 Syncope/pre-syncope 6 Infection
6 Cerebral mass 5 Peripheral vestibular
3 MS related 3 Spinal/PNS
3 Confusion NYD 6 Miscellaneous
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29 of referrals in the ER seen by stroke team
were felt to be NOT stroke/TIA
Wier NU and Buchan AM. JNNP 2005 76863-865.
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Is it a vascular event or not?

• Patient or eye witness account.
• May need clarification dead, numb, dizzy.
• When did it happen?
• What were you doing at the time?

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What things do you need to know?

• Sudden vs gradual onset.
• Modalities involved motor, speech etc.
• Anatomical area involved
• What was the patient doing at the time?
• Accompanying symptoms headache tc.
• History of seizures, migraines, etc.

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Focal versus on focal symptoms

• Localised cerebral ischemia causes focal
  symptoms.
• Non focal symptoms such as faintness , dizziness
  or generalized weakness are rarely due to focal
  cerebral ischemia.

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Focal neurological symptoms

• Motor weakness, clumsiness, ataxia one side
  of body.
• Speech/language difficulty speaking or
  expressing, slurred speech.
• Sensory symptoms abnormal feeling.
• Visual monocular, binocular, diplopia.
• Vestibular vertigo.
• in isolation not usually stroke.

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Non focal Neurological symptoms

• Generalized weakness and/or sensory disturbance.
• Light-headedness
• Faintness
• Blackouts
• Incontinence of urine or feces
• Confusion
• Tinnitus.

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Migraine

• Migraine with aura positive symptoms of focal
  cerebral dysfunction that develop gradually over
  5-20 minutes.
• Visual disturbance most common.
• Paraesthesias, heaviness, may also occur.
• Marching spread of tingling from hand to arm,
  to face over several minutes.
• In younger people headache.

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Migraine equivalent

• Aura without the headache.
• More common with increasing age.
• May not have history of migraines.
• Slow onset and spread and intensification of
  symptoms.

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Syncope/presyncope

• Loss of consciousness is almost never TIA or
  stroke.
• Non focal
• During event- pale, sweaty
• The history is key - lightheaded, what were they
  doing? Dimming of vision
• Precipitants?
• Exclude cardiac causes.

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Seizure

• Partial seizure can mimic of TIA.
• Positive symptoms e.g. tingling, jerking.
• Spread over a minute or so.
• Recurrent, stereotyped episodes.
• May have amnesia for the event.

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• 64 year old woman.
• 20 attacks of pins and needles in her right arm
  and leg over 6 weeks.
• Sensation started in foot and over 1 minute
  spread like water running up her leg. Each
  attack was the same.
• CT head showed glioma in the left parietal lobe.
• Diagnosis partial sensory seizures.

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Seizure 2

• Rarely negative symptoms.
• Todds paresis.
• Transient speech arrest. Cessation of speech,
  aimless staring, amnesia for the event.
• Need to rule out a structural intracranial lesion.

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Structural intracranial lesions

• Subdural hematoma Only 50 have a trauma
  history. Can cause transient symptoms.
• Tumor seizures, intermittent focal neurological
  symptoms.
• Aneurysm or AVM

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Vertigo

• Labyrinthitis severe acute vertigo. Nausea,
  vomiting, ataxia, nystagmus, severe vertigo.
• Menieres disease repeated crises of severe
  rotatory vertigo. Can be acute. Tinnitus,
  deafness, pressure in the ear.
• BPPV vertigo or nystagmus occurring after
  changing head position. Less than 1 minute.
  Dix-Hallpike to diagnose.

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Transient global amnesia

• Sudden disorder of memory.
• Often reported as confusion.
• Antegrade amnesia.
• Some degree of retrograde amnesia.
• Repetitively asks same questions.
• After attack antegrade memory ok.
• No increased risk of stroke.

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Metabolic/toxic disorders

• Hypoglycemia can cause transient and permanent
  focal symptoms. Usually on hypoglycemic agents.
• Stereotyped in an individual.
• Can occurr without the adrenergic symptoms.
• Much check glucose in any Stroke/TIA patient.

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Metabolic/toxic disorders

• Hyperglycemia
• Hyponatremia altered LOC. Focal symptoms rare.
  Can be confused reduced attention level.
• Hypercalcemia usually encephalopathy.

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Wernickes encephalopathy

• Thiamine deficiency.
• Diplopia, ataxia, confusion.
• Mainly seen in alcoholics and malnourished
  elderly.
• TREATABLE thiamine and glucose.
• Reduced transketolase activity.

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Multiple sclerosis

• Usually straightforward.
• Younger 3rd or 4th decade versus 7th or 8th
  decade for stroke.
• Usually subacute onset.
• Previous episodes
• Abnormal examination.
• MRI helpful.

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Mononeuropathy and radiculopathy

• Sensory loss in a dermatomal or nerve
  distribution.
• Cortical sensation intact 2 point
  discrimination, joint position sense.
• Eg. Carpal tunnel syndrome, ulnar neuropathy.

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Motor neurone disease

• Many patients with bulbar ALS are seen in the
  stroke clinic.
• Subtle dysarthria.
• Other signs may be absent UMN. LMN in same limb,
  tongue fasciculations.
• MRI leukoariosis.
• Need to do an EMG to make the diagnosis.

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Psychological disorders

• Cannot be explained by conventional medical
  disease.
• Hyperventilation bilateral limb and perioral
  sensory symptoms.
• Conversion disorders inconsistent exam,
  incompatible with normal anatomy,
• Conversion disorder should not be diagnosed
  without careful thought and assessment of an
  expert.

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So what is important?

• Weakness
• Speech involvement
• Duration gt 10 minutes
• Diabetic
• Hypertension
• Age

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Recurrent Focal Neurologic Spell Prognosis
Johnston C et al. Neurology 2004622015-2020.
lt10 min, multiple, sensory

Recurrent Transient Neurologic spells
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Recurrent Focal Neurologic Spell Prognosis
Johnston C et al. Neurology 2004622015-2020.
lt10 min, multiple, sensory
gt10 min, DM,
motor, speech
Recurrent Transient Neurologic spells
Stroke
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TIA is not so benign Johnston CS et al. JAMA
2000 284 2901-6
OR CI p value Age gt60 1.8
1.3-4.2 0.005 DM 2.0 1.4-2.9
0.001 gt10 min 2.3 1.3-4.2 0.005 Weakness
1.9 1.4-2.6 0.001 Speech 1.5
1.1-2.1 0.01
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TIA Prognosis Benign Malignant

• Timing weeks ago days ago
  hours ago
• Duration sec few minutes gt10 minutes
• Frequency multiple one to few
• Sensory yes with positive sx no
• Motor no yes
• Speech no yes
• Risk factors no Htn, DM,
• Deficit dynamics Mild at onset Severe at
  onset Major early recovery
• No rush to see/ discharge to clinic See
  urgently/admit

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Patient A

• 78 year old woman. At the theatre. Friends
  brought her up to ER because the think she is
  confused.
• Makes perfect sense when you talk to her, but
  then she keeps asking why are we here, were we
  not going to the theatre tonight. Says to her
  friend - when did you dye your hair blond.
  Doesnt remember your name, but otherwise has a
  normal neurolgical exam.
• What would you do?
• Diagnosis? Transient global amnesia.

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Patient B.

• 40 year old woman. Healthy.
• Complaining of numbness and weakness of her right
  arm.
• Started in her hand and migrated up to her
  shoulder and face over the course of 2 or 3
  minutes. Arm felt heavy during it. Symptoms
  persisted for 40 minutes.
• Diagnosis Migraine equivalent.

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Summary

• Nature of symptoms focal or non focal.
• Quality negative or positive.
• Time course sudden gradual migratory pattern.
• Associated symptoms headache, Physical signs.
• Imaging CT or MRI
• Frequency of attacks frequent or stereotyped not
  usually TIA.

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Summary

• TIA is a historical diagnosis so you need to take
  a good history!
• The history will never be easier than on the
  first time you take it from a patient.
• Never skip the details.
• Describe what the patient said. Not what you
  think is happening.

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Summary

• The risk of a recurrent stroke is high after TIA
  5-20.
• Time window for prevention is short.
• High risk patients need to be seen emergently.