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The 10-Second Stroke: A Case Report
Case Report
The 10-Second Stroke: A Case Report Matthew S. Siket, MD, MS,* and Brian Silver, MD†
Background: Acute infarction is detected in a third of patients undergoing diffusionweighted magnetic resonance imaging (DW-MRI) with clinically suspected transient ischemic attack. The longer symptoms are present, the more likely an infarct will be identified on DW-MRI. Events as short as 10 minutes have been reported in association with a DW-MRI lesion. Methods: We present a case of an otherwise healthy man with a 10-second episode of neurologic dysfunction associated with DW-MRI lesions from a cardioembolic source. Results: The atypical symptoms and lack of risk factors for cerebrovascular disease made his diagnosis easy to miss. Conclusions: Early DW-MRI may be of benefit beyond clinical judgment in patients with fleeting symptoms of neurologic dysfunction. Key Words: Transient ischemic attack—TIA—transient symptoms with infarction—stroke—MRI. Ó 2015 by National Stroke Association
Case A 44-year-old man with a history of migraines with aura presented with very brief right-sided weakness and a ‘‘pins and needles’’ sensation. The event, which lasted no more than 10 seconds in his estimation and affected his right face, arm, and leg. He staggered because of the momentary hemiparesis, which quickly resolved.
From the *Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island; and †Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island. Received December 5, 2014; revision received January 12, 2015; accepted January 22, 2015. M.S.S. contributed to the case synopsis and discussion and B.S. contributed to case discussion, article revision, and oversight. M.S.S. reports that there are no disclosures and B.S. reports consulting fees for medical malpractice and adjudication for the Women’s Health Initiative; and honoraria for authorship from Medlink, Medscape, and Oakstone Publishing. Address correspondence to Matthew S. Siket, MD, MS, Department of Emergency Medicine, Alpert Medical School of Brown University, 55 Claverick St.1st Floor, Providence, RI 02903. E-mail: msiket@ lifespan.org. 1052-3057/$ - see front matter Ó 2015 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.01.024
He denied headache, visual symptoms, speech difficulties, or similar symptoms in the past. He never smoked and was an avid exerciser. His initial blood pressure was 143/73, and his neurologic examination was normal. Diffusion-weighted magnetic resonance imaging (DW-MRI) performed 5 hours after symptom onset in the emergency department showed punctate infarctions in the left frontal lobe (Fig 1). Magnetic resonance angiogram of head and neck were unremarkable. Echocardiography revealed a patent foramen ovale (PFO) with atrial septal aneurysm. Delayed appearance of contrast bubbles suggested interpulmonary shunting. Venous duplex of the lower extremities showed no evidence of deep venous thrombosis, but a computed tomography (CT) of chest showed a pulmonary embolus and no pulmonary arteriovenous malformation. Urine toxicology, cardiolipin antibodies, lupus anticoagulant, beta 2 glycoprotein screening, protein C, protein S, antithrombin III, MTFHR, and prothrombin gene 20210A screens were unrevealing. A 30-day cardiac monitor revealed no episodes of paroxysmal atrial fibrillation. He was treated with warfarin for 6 months because of the pulmonary embolus and then switched to aspirin, which he continues. After reviewing the results of recent trials on PFO closure for secondary stroke prevention, he declined the procedure. He remained asymptomatic at 1-year follow-up.
Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2015: pp e1-e2
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Figure 1. DW-MRI brain images. (A) DWI, (B) apparent diffusion coefficient (ADC), (C) T2 Fluid Attenuated Inversion Recovery (FLAIR) images showing acute punctate right frontoparietal cortical infarcts (red arrows).
Discussion We present a patient with symptoms lasting no more than 10 seconds associated with an anatomically corresponding acute infarction on DW-MRI. His symptoms might be ascribed to a migrainous event given his age and history of migraine with auras.1 However, he had no headache at the time of the event and symptoms lasted less than 60 minutes, which are discordant with a diagnosis of migrainous infarction, according the International Classification of Headache Disorders-II definition.2 He had an asymptomatic pulmonary embolus detected on CT of chest, which was performed because of an echocardiogram suggesting a pulmonary arteriovenous malformation. Like the ischemic infarction, the cause of the pulmonary embolus remained cryptogenic, despite extensive hematologic testing. Therefore, warfarin was discontinued after the period deemed appropriate to treat the pulmonary embolus. A statistically significant reduction in secondary stroke risk with PFO closure was not shown in 3 randomized trials, which swayed the patient not to pursue that course of treatment. Despite the finding that a third of patients with suspected transient ischemic attack (TIA) imaged with DW-MRI are found to have acute infarction, his absence of underlying cerebrovascular disease risk factors and very brief duration of symptoms might have provided false reassurance.3,4 Irrespective of symptom duration or comorbid risk factors, DW-MRI abnormalities confer nearly a 20-fold increased risk of subsequent short-term recurrent stroke compared with those with normal studies.5,6 DW-MRI is far more sensitive for small areas of infarction than CT when obtained early. A recent study found that of the 89 patients with a positive MRI shortly after symptom onset, 30% of patients had a negative scan at 90 days.7 Although a rarity in the emergency department setting, early DW-MRI maximizes diagnostic and prognostic accuracy. Whether an MRI-based versus CT-based
evaluation of patients with stroke or TIA improves outcome is uncertain at this time.8 Nevertheless, patient classification with respect to final diagnosis is altered depending on the type and timing of imaging. Without DW-MRI, TIA can be clinically indistinct from transient symptoms with infarction. An alternative nomenclature emphasizing the spectrum of disease is needed, such as ‘‘acute ischemic cerebrovascular syndrome’’ as has been previously proposed.9 Future studies will need to address these issues given the potential impact on epidemiologic classification and eligibility for studies.
References 1. Kidwell CS, Alger JR, Di Salle F, et al. Diffusion MRI in patients with transient ischemic attacks. Stroke 1999;30: 1174-1180. 2. International Headache Society Classification ICHD-II 1.5.4 Migrainous infarction. Available at: http://ihsclassification.org/en/02_klassifikation/02_teil1/01.05.04_ migraine.html. Accessed January 11, 2015. 3. Arsava EM, Furie KL, Schwamm LH, et al. Prediction of early stroke risk in transient symptoms with infarction: relevance to the new tissue-based definition. Stroke 2011; 42:2186-2190. 4. Inatomi Y, Kimura K, Yonehara T, et al. DWI abnormalities and clinical characteristics in TIA patients. Neurology 2004;62:376-380. 5. Sorensen AG, Ay H. Transient ischemic attack: definition, diagnosis, and risk stratification. Neuroimaging Clin N Am 2011;21:303-313. 6. Giles MF, Albers GW, Amarenco P, et al. Early stroke risk and ABCD2 score performance in tissue- vs time-defined TIA: a multicenter study. Neurology 2011;77:1222-1228. 7. Moreau F, Modi J, Almekhlafi M, et al. Early magnetic resonance imaging in transient ischemic attack and minor stroke: do it or lose it. Stroke 2013;44:671-674. 8. Hefzy H, Neil E, Penstone P, et al. The addition of MRI to CT based stroke and TIA evaluation does not impact one year outcomes. Open Neurol J 2013;7:17-22. 9. Kidwell CS, Warach S. Acute ischemic cerebrovascular syndrome: diagnostic criteria. Stroke 2003;34:2995-2998.
The 10-Second Stroke: A Case Report Matthew S. Siket, MD, MS,* and Brian Silver, MD†
Background: Acute infarction is detected in a third of patients undergoing diffusionweighted magnetic resonance imaging (DW-MRI) with clinically suspected transient ischemic attack. The longer symptoms are present, the more likely an infarct will be identified on DW-MRI. Events as short as 10 minutes have been reported in association with a DW-MRI lesion. Methods: We present a case of an otherwise healthy man with a 10-second episode of neurologic dysfunction associated with DW-MRI lesions from a cardioembolic source. Results: The atypical symptoms and lack of risk factors for cerebrovascular disease made his diagnosis easy to miss. Conclusions: Early DW-MRI may be of benefit beyond clinical judgment in patients with fleeting symptoms of neurologic dysfunction. Key Words: Transient ischemic attack—TIA—transient symptoms with infarction—stroke—MRI. Ó 2015 by National Stroke Association
Case A 44-year-old man with a history of migraines with aura presented with very brief right-sided weakness and a ‘‘pins and needles’’ sensation. The event, which lasted no more than 10 seconds in his estimation and affected his right face, arm, and leg. He staggered because of the momentary hemiparesis, which quickly resolved.
From the *Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island; and †Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island. Received December 5, 2014; revision received January 12, 2015; accepted January 22, 2015. M.S.S. contributed to the case synopsis and discussion and B.S. contributed to case discussion, article revision, and oversight. M.S.S. reports that there are no disclosures and B.S. reports consulting fees for medical malpractice and adjudication for the Women’s Health Initiative; and honoraria for authorship from Medlink, Medscape, and Oakstone Publishing. Address correspondence to Matthew S. Siket, MD, MS, Department of Emergency Medicine, Alpert Medical School of Brown University, 55 Claverick St.1st Floor, Providence, RI 02903. E-mail: msiket@ lifespan.org. 1052-3057/$ - see front matter Ó 2015 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.01.024
He denied headache, visual symptoms, speech difficulties, or similar symptoms in the past. He never smoked and was an avid exerciser. His initial blood pressure was 143/73, and his neurologic examination was normal. Diffusion-weighted magnetic resonance imaging (DW-MRI) performed 5 hours after symptom onset in the emergency department showed punctate infarctions in the left frontal lobe (Fig 1). Magnetic resonance angiogram of head and neck were unremarkable. Echocardiography revealed a patent foramen ovale (PFO) with atrial septal aneurysm. Delayed appearance of contrast bubbles suggested interpulmonary shunting. Venous duplex of the lower extremities showed no evidence of deep venous thrombosis, but a computed tomography (CT) of chest showed a pulmonary embolus and no pulmonary arteriovenous malformation. Urine toxicology, cardiolipin antibodies, lupus anticoagulant, beta 2 glycoprotein screening, protein C, protein S, antithrombin III, MTFHR, and prothrombin gene 20210A screens were unrevealing. A 30-day cardiac monitor revealed no episodes of paroxysmal atrial fibrillation. He was treated with warfarin for 6 months because of the pulmonary embolus and then switched to aspirin, which he continues. After reviewing the results of recent trials on PFO closure for secondary stroke prevention, he declined the procedure. He remained asymptomatic at 1-year follow-up.
Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2015: pp e1-e2
e1
M.S. SIKET AND B. SILVER
e2
Figure 1. DW-MRI brain images. (A) DWI, (B) apparent diffusion coefficient (ADC), (C) T2 Fluid Attenuated Inversion Recovery (FLAIR) images showing acute punctate right frontoparietal cortical infarcts (red arrows).
Discussion We present a patient with symptoms lasting no more than 10 seconds associated with an anatomically corresponding acute infarction on DW-MRI. His symptoms might be ascribed to a migrainous event given his age and history of migraine with auras.1 However, he had no headache at the time of the event and symptoms lasted less than 60 minutes, which are discordant with a diagnosis of migrainous infarction, according the International Classification of Headache Disorders-II definition.2 He had an asymptomatic pulmonary embolus detected on CT of chest, which was performed because of an echocardiogram suggesting a pulmonary arteriovenous malformation. Like the ischemic infarction, the cause of the pulmonary embolus remained cryptogenic, despite extensive hematologic testing. Therefore, warfarin was discontinued after the period deemed appropriate to treat the pulmonary embolus. A statistically significant reduction in secondary stroke risk with PFO closure was not shown in 3 randomized trials, which swayed the patient not to pursue that course of treatment. Despite the finding that a third of patients with suspected transient ischemic attack (TIA) imaged with DW-MRI are found to have acute infarction, his absence of underlying cerebrovascular disease risk factors and very brief duration of symptoms might have provided false reassurance.3,4 Irrespective of symptom duration or comorbid risk factors, DW-MRI abnormalities confer nearly a 20-fold increased risk of subsequent short-term recurrent stroke compared with those with normal studies.5,6 DW-MRI is far more sensitive for small areas of infarction than CT when obtained early. A recent study found that of the 89 patients with a positive MRI shortly after symptom onset, 30% of patients had a negative scan at 90 days.7 Although a rarity in the emergency department setting, early DW-MRI maximizes diagnostic and prognostic accuracy. Whether an MRI-based versus CT-based
evaluation of patients with stroke or TIA improves outcome is uncertain at this time.8 Nevertheless, patient classification with respect to final diagnosis is altered depending on the type and timing of imaging. Without DW-MRI, TIA can be clinically indistinct from transient symptoms with infarction. An alternative nomenclature emphasizing the spectrum of disease is needed, such as ‘‘acute ischemic cerebrovascular syndrome’’ as has been previously proposed.9 Future studies will need to address these issues given the potential impact on epidemiologic classification and eligibility for studies.
References 1. Kidwell CS, Alger JR, Di Salle F, et al. Diffusion MRI in patients with transient ischemic attacks. Stroke 1999;30: 1174-1180. 2. International Headache Society Classification ICHD-II 1.5.4 Migrainous infarction. Available at: http://ihsclassification.org/en/02_klassifikation/02_teil1/01.05.04_ migraine.html. Accessed January 11, 2015. 3. Arsava EM, Furie KL, Schwamm LH, et al. Prediction of early stroke risk in transient symptoms with infarction: relevance to the new tissue-based definition. Stroke 2011; 42:2186-2190. 4. Inatomi Y, Kimura K, Yonehara T, et al. DWI abnormalities and clinical characteristics in TIA patients. Neurology 2004;62:376-380. 5. Sorensen AG, Ay H. Transient ischemic attack: definition, diagnosis, and risk stratification. Neuroimaging Clin N Am 2011;21:303-313. 6. Giles MF, Albers GW, Amarenco P, et al. Early stroke risk and ABCD2 score performance in tissue- vs time-defined TIA: a multicenter study. Neurology 2011;77:1222-1228. 7. Moreau F, Modi J, Almekhlafi M, et al. Early magnetic resonance imaging in transient ischemic attack and minor stroke: do it or lose it. Stroke 2013;44:671-674. 8. Hefzy H, Neil E, Penstone P, et al. The addition of MRI to CT based stroke and TIA evaluation does not impact one year outcomes. Open Neurol J 2013;7:17-22. 9. Kidwell CS, Warach S. Acute ischemic cerebrovascular syndrome: diagnostic criteria. Stroke 2003;34:2995-2998.