TIA and Stroke mimics - “spells”

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

2. 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.

3. The Definition of Stroke/ TIA A clinical syndrome characterized by the suddenonset of a focal neurological deficit presumed to be on a vascular basis.

4. What is a TIA and why is it not that simple… • Diagnosis is made on history • Don’t take what you are told for granted. • numb, dead, heavy, weak – all mean different things to different people. • What else could it be.

6. Conditions Misdiagnosed as TIA • Migraine aura • Syncope, postural hypotension • Seizure • Vertigo • Transient Global Amnesia • Anxiety/Hyperventilation • Confusion • Unexplained fall • Peripheral nerve palsy

7. 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.

8. 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 12 29% of referrals in the ER seen by stroke team were felt to be NOT stroke/TIA Wier NU and Buchan AM. JNNP 2005; 76:863-865.

9. 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?

10. 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.

11. 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.

12. 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.

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

15. 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.

17. 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.

19. 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.

20. 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.

21. 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.

22. Seizure 2 • Rarely: negative symptoms. • Todd’s paresis. • Transient speech arrest. Cessation of speech, aimless staring, amnesia for the event. • Need to rule out a structural intracranial lesion.

23. Structural intracranial lesions • Subdural hematoma: Only 50% have a trauma history. Can cause transient symptoms. • Tumor: seizures, intermittent focal neurological symptoms. • Aneurysm or AVM

26. Vertigo • Labyrinthitis: severe acute vertigo. Nausea, vomiting, ataxia, nystagmus, severe vertigo. • Meniere’s 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.

27. 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.

28. 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.

29. Metabolic/toxic disorders • Hyperglycemia • Hyponatremia: altered LOC. Focal symptoms rare. Can be “confused” – reduced attention level. • Hypercalcemia: usually encephalopathy.

30. Wernicke’s encephalopathy • Thiamine deficiency. • Diplopia, ataxia, confusion. • Mainly seen in alcoholics and malnourished elderly. • TREATABLE: thiamine and glucose. • Reduced transketolase activity.

31. 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.

33. 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.

34. 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.

35. 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.

36. So what is important? • Weakness • Speech involvement • Duration > 10 minutes • Diabetic • Hypertension • Age

37. Recurrent Focal Neurologic Spell Prognosis Johnston C et al. Neurology 2004;62:2015-2020. <10 min, multiple, sensory Recurrent Transient Neurologic spells

38. Recurrent Focal Neurologic Spell Prognosis Johnston C et al. Neurology 2004;62:2015-2020. <10 min, multiple, sensory >10 min, DM, motor, speech Recurrent Transient Neurologic spells Stroke

39. TIA is not so benign Johnston CS et al. JAMA 2000; 284: 2901-6 OR CI p value Age >60 1.8 1.3-4.2 0.005 DM 2.0 1.4-2.9 0.001 >10 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

40. TIA Prognosis Benign Malignant Timing weeks ago days ago hours ago Duration sec – few minutes >10 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

41. 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”. Doesn’t remember your name, but otherwise has a normal neurolgical exam. • What would you do? • Diagnosis? Transient global amnesia.

42. 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.

43. 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.

44. 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.

45. 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.