Using the Neuro Exam to Diagnose Mimics Jennifer Simpson, MD Neurohospitalist Vascular Neurologist None 2 Review the differential diagnosis for stroke Identify patients physical examination findings that can help differentiate between stroke and a mimic Discuss portions of the history that helps to clue you into a stroke mimic 3
66 year old female found down by husband, now confused. Hx of liver transplant, diabetes type II On exam, Awake, confused, especially R/L, can t perform simple math Mild right lower facial droop Pronator drift and leg drift on right 4 5 6
Ictal phenomenon Spreading symptoms can be described Positive phenomenon Stereotyped 7 Post-Ictal state Can follow generalized or partial seizures Confusion Hemiparesis Improvement with time Seizures can present at the onset of stroke 8 ROSIER: Recognition of Stroke in the Emergency Department Sensitivity of 83%, Specificity of 44% Positive if >1 (face weak)+(arm weak)+(leg weak)+ (speech disturbance)+(visual field)-syncope-seizure FAST: Face Arm Speech Test Sensitivity of 81%, specificity 39% If face, arm weaknessor speech disturbance had abnormality 9
Libman 1995: Mimic: Decreased level of consciousness Normal eye movement Stroke Abnormal visual fields DBP >90 Afib History of angina 11 Hand 2006: Inability to walk Loss of consciousness Seizure at onset No lateralizing symptoms/no neurological signs NIHSS 0 or very low Confusion Signs inconcistent with sympoms Signs inconsistent with a vascular territory Signs in other systems (like lung crackles) Hemiplegic migraine can mimic stroke Headache can be present at the onset, during, or after Sensory disturbances Cherio-oral Positive phenomenon can be present Sparks, sparkles, scotoma, slowly developing hemianopia Marching progression 12
13 At least 2 of the following, without motor weakness: Dysarthria Vertigo Tinnitus Hypacusia Diplopia Visual symptoms in both nasal and temporal fields Decreased level of consciousness Simultaneous bilateral parasthesias Dizziness/vertigo Gati ataxia Bilateral acral, perioral or lingual numbness Vomiting Occipital headacehs Usually adolescent girls 14 Stroke with clinical features of migraine AVMs can masquerade as migraine CADASIL Patients with migraine at higher risk for stroke Relative risk meta-analysis 2.16 Drugs patients with migraine take increase risk of stroke Ergots Triptans 15
16 Young patients Women History of psychiatric disease Fluctuating/Inconsistent examination findings Symptoms not localizable to vascular territory Trigger in many Physical injury Pain (migraine) Sleep paralyssis Flexors weak in arms, extensors weak in legs Opposite of the pyramidal tract Inconsistency during examination Fluctuating levels of weakness Ability to walk to bed, but not lift leg off bed Hip adductors 17 Give way Normal strength for a second, then becomes weak Count to 3 Test bilaterally harder to have one side be weak Face weakness Pseudoptosis Overactivity of platysma 18
Daroff: Bradley s Neurology in Clinical Practice, 6 th Ed. Figure 82.2 19 Dragging gait Internally or externally rotated leg with walking Ability to stand on one foot Astasia-Abasia Knee-buckling Crouching Tightrope-walker s gait 20 Helpful when doing the reflex exam Delayed jerking that is more than expected Functional tremor Sensory examination Remember pain and temperature go together, as do vibration and proprioception The forehead only has 1 bone Splitting midline 21
Vision problems Convergence nystagmus Binocular double vision Total visual loss Ask to sign name Optokinetic strips/drums Mirror Tubular visual loss Should be a cone Hemifield loss with a normal contra eye 22 Intermittently slurred Stuttering Wispering Speech is generally worse with formal testing, but is much better when talking about something they are interested in. 23 24
Mohr JP. Stroke : pathophysiology, diagnosis, and management. 5th ed. Philadelphia, PA: Elsevier/Saunders; 2011. Daroff RB, Bradley WG. Bradley's neurology in clinical practice. 6th ed. Philadelphia, PA: Elsevier/Saunders; 2012. Hand PJ et al. Distinguishing between stroke and mimic at the bedside: Brain Attack Study. Stroke. 2006; 37:769-775. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol. Nov 1995;52(11):1119-1122. Whiteley WN, et al. Clinical Scores for the Identification of Stroke and Transient Ischemic Attack in the Emergency Department: A cross-sectional study. J Neurol Neurosurg Psychiatry. 2011; 82:1006-1010.