Stroke mimics. Case 1. Acute cases. History. 43 year old healthy male Shortly after awakening developed:

Transcription

1 Stroke mimics Acute cases Gothenburg 21. may 2007 History Case 1 43 year old healthy male Shortly after awakening developed: Left-sided lower facial weakness Left-sided arm paralysis and weakness in leg Hypoestesia in left face, arm and leg Unawareness of left side CB

2 Case 1 DWI ADC CB Case 1 T2 FLAIR CB

3 Case 1 1 month earlier he was thoroughly examined at the medical department due to unknown fever and headache X-ray of thorax normal Bone scientigrafi normal Aseptic fluid from swollen foot joint A tooth root filling was done Iv. Antibiotics for 2 days Finally temperature and CRP normalized but headache continued Case 1 Acute MRA CB

4 Case 1 Thrombolysis??? 5 minutes left of the 3 hour time window! Lumbar puncture: 60 monocytes Increase spinal protein High dose iv. Steroid PWI before steroid and two hours later PWI before PWI two hours later

5 Case 1 DWI 3 weeks after the acute episode CB Case 1 3 weeks after the acute episode CB

6 Case 1 3 weeks after the acute episode CB Case 2 History 25 year old woman, former healthy with symptoms during the last two months: Cognetive complaints: difficulties in memory and orientation 1. A depression was suspected antidepressive medication Weakness and ataksia of left hand and later also right arm and leg Dysartria Left-sided lower facial weakness Swollowing difficulties Loss of weight ( kg) Fever Dysforic mood Neurological examination showed hyperrefleksia KH

7 Case 2 MR at admission KH Case 2 MR at admission KH

8 Case 2 MR at admission KH Case 2 MR at admission KH

9 Case 2 CT after 2 days KH Case 2 CT after 2½ days KH

10 Case 2 CT after 5 days KH MR (2 days before admission): hyperintense periventricular lesions - a diagnose of Multiple Sclerosis (MS) was suspected MR (at admission): characteristic changes of cerebral arteries Intensive immunosupressive treatment but the disease progressed The patient died after 8 days KH

11 Cerebral angiitis Radiological characteristics: 2 or more stenosis occouring in 2 separate artery territories DSA gold standard sensitivity 60-80% specificity 30% Brain biopsy specificity 80% false negative 53% MRA?? MR-A A in cases with suspected cerebral angiitis 3D TOF: Multiple stenosis DSA (ICA and vert dx): Multiple stenosis

12 Cerebral angiitis (3D TOF MRA) Patient 1 Patient 2 angiitis: > 3 stenosis Cerebral angiitis Segmental stenosis: A cerebri anterior A cerebri media A case of: Varicella meningitis

13 Case 3 Acute admission due to suspected stroke within 3 hour time window for thrombolysis History of TIA (transient ischemic attack) at local hospital 3 months earlier Acute symptoms: Sudden decrease in concioussness Speaking difficulty Right-sided parestesia in face and arm Spasms in right arm Weakness in lower right face and arm JB Case 3 DWI ADC JB

14 Case 3 T1 FLAIR JB Case 3, 4 months later T1 T1 +k JB

15 Case 3 JB Case 4 36 year old healthy woman 2 days of severe headache located in the neck Chiropractor treatment started Developed a progressive left-sided arm and leg weakness and decrease in sensibility Diagnose? Examination showed: Left-sided hemiparalysis and decreased sensibility. Increased tendon reflexes and Babinski response. BT 200/135 MMK

16 Case 4 MMK Case 5 57 year old man Hortons headache for 20 years Vascular risk factors: Normal blood pressure Total Cholesterol within normal range Non smoker Several TIA episodes during the past 10 years 5 brothers of whom 1 brother had MS and 1 was demented HF

17 Case 5 HF CADASIL Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencefalopathy Mutations in NOTCH 3 genom on chromosome 19 Pathology: Non-arteriosclerotic angiopaty without amyloid deposits - leptomeningeal and perforating arteries of the brain - osmiofilic material located in wessel membran MR: WML located to anterior temporal lobes, frontal lobes and capsula externa (Markus et al.neurology 2002;59:1134)

18 CADASIL Clinical characteristics Start of symptoms between age (SAE > 65år) Recurent ischemic cerebral events infartions Progressive cognitive deficits - migraene headaches, psychiatric symptoms (depression) Neurological symptoms e.g. hemiplegia - subcortical dementia severely disabled (years) CADASIL

19 Case 6 61 year old healthy man 2 days unwell with fever 9:30 left-sided ataxia - acute admission for thrombolysis 10:07 neurological examination: Full conscious, left-sided hemianopia,, left-sided arm and leg weakness and decreased sensibility, left-sided ataxia and decreased awareness to left side. BP 170/100 mmhg, puls 80. Diagnose? Temperature 39,9 - No stiffness in neck ECG: sinusrythme Stet c.: chest bruit Blood glucose 12,7 mmol Diagnose? GD Case 6 DWI normal - PWI not done GD

20 Case 6 MR: T1 GD Case 6 Lab tests: neutrofilocytosis (20x10 9 ) Lumbar puncture immediate after MRI: Purulent spinal fluid iv. Antibiotics was started Microscopy showed meningococ infection The patient went unconscious Long intensive treatment at department of infectious medicine Excellent outcome after 3 months GD

21 Case 7 43 year old man 2 weeks with dizziness, dysartria, atactic working Cerebral MR : ADEM-HIV HIV-lymfoma? Cerebral MR : Progression Cerebral MR : Progression Brain Biopsy : not possible Iv. Steroid treatment and clinical improvement Cerebral MR : Regression FG Case 7 MR T2 MR FLAIR FG

22 Case 7 MR FLAIR MR FLAIR FG Case 7 FG

23 ADEM Akut Demyelinating Encefalo Myelitis non-specific upper resp. infections 35% Vaccination 12% GI symptoms 11% non-specific fever 7% Varicella 5% Herpes simp. encefalit 2% Mumps (parotitis) 1% Rubella 1% unspecified 26% (Tenenbaum et al. Neurology. 2002;59(8):1224) ADEM Clinical findings at admission Pyramide tract symptoms 85% Acute hemiplegia 76% Decreased consciousness 69% Cerebellar ataxia 50% Cranial nerve paresis 44% Meningismus 43% Siezures 35% Headache/ vomiting 32% Medullar involvement 24% Loss of vivion 23% Dysphasia 21% Ekstra pyramide symptoms 12% Paræstesia 2% (Tenenbaum et al. Neurology. 2002;59(8):1224)

24 Case 8 51year old woman Former healthy Headache and decreased consciousness Symptoms for a few hours Symptoms progressive - Right-sided hemiplegia ILM Case 8 ILM

25 Case 8 ILM HSV 2: New born babies Herpes simplex - Diffuse brain affection HSV 1: children and adults Activation of latent infection located in ganglion Gasseri Most common virus encephalitis Full scale with necrosis and haemorrhagic lesions Limbic system often involved (HSV 1) Temporal lobes, gyrus cinguli, subcortical frontal