Stroke-mimic and scleroderma in "coup de sabre": Case report / Stroke-mimic y esclerodermia en «coup de sabre¼: reporte de caso

ABSTRACT A case is presented of an atypical manifestation of localized scleroderma. The patient is a 30-year-old Caucasian women with localized facial scleroderma "coup de sabre", with clinical stability foryears. She was seen in the Emergency Department due to a sudden lack of sensitivity in her left side, and was treated as a stroke. Complementary tests showed intracranial parenchymal images that were finally attributed to the localized scleroderma. After a comprehensive literature review, this presentation was more frequent than expected. This is why neurological symptoms should be carefully evaluated in these patients. This is the first stroke-mimic case reported.

RESUMEN A continuación, presentamos el caso de una paciente con una manifestación atípica para esclerodermia localizada. Mujer de 30 an˜ os con esclerodermia localizada facial en sabré¼, con estabilidad clínica de las lesiones durante an˜ os. En el 2017 acude al servicio de urgencias por un cuadro de alteración sensitiva en hemicuerpo izquierdo que fue tratada como un ictus. En los estudios complementarios se objetivaron lesiones parenquimatosas finalmente atribuibles a la esclerodermia localizada. Tras revisar la literatura, este tipo de lesiones es más frecuente de lo esperado, por lo que parece obligatorio dedicar más atención a los síntomas neurológicos en los pacientes con esclerodermia localizada. Este es el primer caso de stroke-mimic reportado.

Stroke-mimics in stroke-units. Evaluation after changes imposed by randomized trials / Imitadores de AVC em unidades de AVC. Avaliação após alterações impostas por ensaios randomizados

Abstract A larger therapeutic window for stroke treatment requires a significant change in the organization of emergency services, avoiding the increase in number of imaging exams and indirectly the time to treatment. Objective: To highlight the relation between faster clinical evaluation and stroke over-suspicion and consequently excessive imaging acquisition. To identify predictors of ischemic stroke and stroke mimics (SM), aiming for better patient selection for comprehensive neuroimaging and reperfusion therapies. Methods: Retrospective, cohort, observational, single-center study that reviewed all consecutive files of patients presenting with acute neurological symptoms who underwent CT scan or MRI from July 1, 2016 to July 1, 2017. Results: 736 patient files were reviewed. 385 patients (52.3%) presented with confirmed acute ischemic infarct, 93 (12.6%) had another brain lesion mimicking acute ischemia, and 258 (35.1%) had normal imaging. Acute stroke was more frequent in elderly patients with atrial fibrillation, arterial hypertension, or dysarthria or right motor impairment. Stroke mimic was associated with female patients with low vascular risk factors, low NIHSS, and patients with decreased level of consciousness or symptoms suggestive of posterior circulation. Discussion: 47.7% of all patients seen at the stroke unit did not have acute stroke lesions. Clinical assessment data have been used to provide indicators of acute stroke and stroke mimic patients, and symptoms corresponding to acute stroke and stroke mimic seem to be similar in the literature. Conclusion: Considering that the number of patients admitted for stroke treatment will increase even further with a larger therapeutic window for mechanical thrombectomy and for thrombolysis, a diagnostic decision-making algorithm for stroke patients is required in order to reinforce the suspicion of stroke indicating an urgent MRI.

Resumo Uma janela terapêutica maior para o tratamento do AVC exige uma mudança significativa na organização dos serviços de emergência, para evitar o aumento do número de exames de imagem e indiretamente o tempo de tratamento. Objetivo: destacar a relação entre avaliação clínica mais rápida e suspeita de acidente vascular cerebral e, consequentemente, aquisição de imagem excessiva, e identificar preditores de acidente vascular cerebral isquêmico e imitações de acidente vascular cerebral (SM), visando uma melhor seleção de pacientes para terapias abrangentes de neuroimagem e reperfusão. Métodos: estudo observacional de coorte retrospectivo, em centro único, que revisou todos os arquivos consecutivos de pacientes com sintomas neurológicos agudos submetidos à tomografia computadorizada ou ressonância magnética de 1 de julho de 2016 a 1 de julho de 2017. Resultados: Foram revisados 736 prontuários. 385 pacientes (52,3%) apresentaram infarto isquêmico agudo confirmado, 93 (12,6%) apresentaram outra lesão cerebral imitando isquemia aguda e 258 (35,1%) apresentaram imagem normal. O AVC agudo foi mais frequente em pacientes idosos com fibrilação atrial, hipertensão arterial, ou disartria ou comprometimento motor direito. A imitação de acidente vascular cerebral foi associada a pacientes do sexo feminino com baixos fatores de risco vascular, NIHSS baixo e pacientes com diminuição do nível de consciência ou sintomas sugestivos de circulação posterior. Discussão: 47,7% de todos os pacientes atendidos na unidade de AVC não apresentaram lesões agudas de AVC. Conclusão: Considerando que o número de pacientes admitidos para tratamento de AVC aumentará ainda mais com uma janela terapêutica maior para trombectomia e trombólise IV, é necessário um algoritmo de tomada de decisão diagnóstica para pacientes com AVC, a fim de reforçar a suspeita de AVC indicando uma imagem cerebral urgente.

Imitador De Ictus Debido A Trombosis Venosa Cerebral / Stroke Mimic Due To Cerebral Venous Thrombosis

RESUMEN Introducción: Un imitador de ictus es toda aquella patología no vascular que se presenta como un ictus isquémico agudo. La presentación clínica, factores epidemiológicos, el tiempo de inicio, la distribución vascular y la disponibilidad de pruebas de imagen, son factores que ayudan a diferenciarlos. Caso clínico: Presentamos un caso, de una mujer de la tercera edad que fue llevada a urgencias por hemiparesia izquierda de cinco horas de evolución. La evolución clínica y las pruebas complementarias permitieron excluir el diagnóstico de ictus isquémico agudo. La semiología fue explicada por una parálisis de Todd prolongada que se comportó como imitador de ictus en la fase aguda y las crisis epilépticas se produjeron en el contexto de una trombosis venosa cerebral. Comentarios: Los imitadores de ictus, al contrario del ictus isquémico agudo, ocurren en pacientes más jóvenes, tienen menos factores de riesgo vascular, menor puntuación de NIHSS, menos afasia y disfagia. Las principales causas son crisis epilépticas y síncopes. Deben considerarse también migrañas, neoplasias, alteraciones tóxicas o metabólicas, encefalopatías y trastornos funcionales. Realizar un estudio neurovascular completo y pruebas dirigidas nos permitirán el diagnóstico.

ABSTRACT Introduction: A stroke mimic is any non-vascular pathology that presents as an acute ischemic stroke. The clinical presentation, the epidemiological factors, the time to onset, vascular distribution and the availability of imaging tests are factors that help to differentiate them. Case report: We present a case, of a woman of the third age who was taken to the emergency department due to a five-hour history of left hemiparesis. The clinical evolution and the supplementary tests allowed to exclude the diagnosis of acute ischemic stroke. The semiology was explained by a prolonged Todd's palsy that behaved as a stroke mimic at the acute phase and the seizures occurred in the context of a cerebral venous thrombosis. Comments: Stroke mimics, in contrast to acute ischemic stroke, occur in younger patients, have fewer vascular risk factors, lower NIHSS score, less aphasia and dysphagia. The main causes are seizures and syncope. Migraines, neoplasms, toxic or metabolic alterations, encephalopathies and functional disorders should also be considered. To perform a complete neurovascular study and directed tests will allow us to make the diagnosis.