Top

European Radiology

Published in:

01-05-2018 | Neuro

Advanced CT for diagnosis of seizure-related stroke mimics

Authors: Friederike Austein, Monika Huhndorf, Johannes Meyne, Helmut Laufs, Olav Jansen, Thomas Lindner

Published in: European Radiology | Issue 5/2018

Abstract

Background and purpose

It is assumed that up to 30 % of clinically diagnosed acute ischaemic strokes (AIS) are actually stroke mimics (SM). Our aim was to evaluate the usefulness of advanced CT including CT angiography (CTA) and CT perfusion (CTP) findings when distinguishing AIS from seizure-related SM.

Methods

Over a 22-month period data were gathered of patients who presented to our stroke centre with AIS-like symptoms and were examined immediately with an advanced CT, analysed and evaluated by two experienced neuroradiologists who preferred SM rather than AIS. All these patients additionally received electroencephalography and follow-up imaging. CTA was the important feature to exclude vessel occlusion or haemodynamic relevant stenosis. Perfusion patterns were retrospectively analysed qualitatively.

Results

The most common perfusion abnormality was cortical hyperperfusion (22/37 [59.5 %] patients) followed by a hypoperfusion pattern with a cortical-subcortical involvement (15/37 [40.5 %] patients) without evidence of vessel occlusion or stenosis. Seizure-related hyper- and hypoperfusion patterns typically crossed the normal anatomical vascular territories boundaries.

Conclusion

Beyond its use in core and penumbra estimation, advanced CT provides important information to emergency physicians in the difficult clinical diagnosis when differentiating between AIS and seizure-related symptoms with an important impact on therapeutic decision-making.

Key points

• Advanced CT helps to differentiate between ischaemic strokes and stroke mimics.

• Seizure-related perfusion patterns are distinct from ischaemia hypoperfusion.

• Advanced CT could improve rapid adequate treatment for AIS and seizure events.

Hand PJ, Kwan J, Lindley RI, Dennis MS, Wardlaw JM (2006) Distinguishing between stroke and mimic at the bedside. Stroke 37:769–775CrossRefPubMed

Scott PA, Silbergleit R (2003) Misdiagnosis of stroke in tissue plasminogen activator–treated patients: characteristics and outcomes. Annals of emergency medicine 42:611–618CrossRefPubMed

Wintermark M, Luby M, Bornstein NM et al (2015) International survey of acute stroke imaging used to make revascularization treatment decisions. International Journal of Stroke 10:759–762CrossRefPubMedPubMedCentral

Campbell BC, Mitchell PJ, Kleinig TJ et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. New England Journal of Medicine 372:1009–1018CrossRefPubMed

Gelfand J, Wintermark M, Josephson S (2010) Cerebral perfusion-CT patterns following seizure. European journal of neurology 17:594–601CrossRefPubMed

Lie C-H, Seifert M, Poggenborg J, Fink GR, Burghaus L (2011) Perfusion computer tomography helps to differentiate seizure and stroke in acute setting. Clin Neurol Neurosurg 113:925–927CrossRefPubMed

Mathews MS, Smith WS, Wintermark M, Dillon WP, Binder DK (2008) Local cortical hypoperfusion imaged with CT perfusion during postictal Todd’s paresis. Neuroradiology 50:397–401CrossRefPubMed

Hedna VS, Shukla PP, Waters MF (2012) Seizure mimicking stroke: role of CT perfusion. J Clin Imaging Sci 2

Hauf M, Slotboom J, Nirkko A, Von Bredow F, Ozdoba C, Wiest R (2009) Cortical regional hyperperfusion in nonconvulsive status epilepticus measured by dynamic brain perfusion CT. American Journal of Neuroradiology 30:693–698CrossRefPubMed

10.

Hassan AE, Cu SR, Rodriguez GJ, Qureshi AI (2012) Regional cerebral hyperperfusion associated with postictal paresis. Journal of vascular and interventional neurology 5:40PubMedPubMedCentral

11.

Guerrero WR, Dababneh H, Eisenschenk S (2012) The role of perfusion CT in identifying stroke mimics in the emergency room: a case of status epilepticus presenting with perfusion CT alterations. Int J Emerg Med 5:4CrossRefPubMedPubMedCentral

12.

Masterson K, Vargas MI, Delavelle J (2009) Postictal deficit mimicking stroke: role of perfusion CT. J Neuroradiol 36:48–51CrossRefPubMed

13.

Goyal N, Male S, Al Wafai A, Bellamkonda S, Zand R (2015) Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment. Journal of Stroke and Cerebrovascular Diseases 24:828–833CrossRefPubMed

14.

Meierkord H, Boon P, Engelsen B et al (2010) EFNS guideline on the management of status epilepticus in adults. European journal of neurology 17:348–355CrossRefPubMed

15.

Sylaja P, Dzialowski I, Krol A, Roy J, Federico P, Demchuk AM (2006) Role of CT angiography in thrombolysis decision-making for patients with presumed seizure at stroke onset. Stroke 37:915–917CrossRefPubMed

16.

Campbell BC, Christensen S, Levi CR et al (2011) Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core. Stroke 42:3435–3440CrossRefPubMed

17.

Olivot JM, Mlynash M, Zaharchuk G et al (2009) Perfusion MRI (Tmax and MTT) correlation with xenon CT cerebral blood flow in stroke patients. Neurology 72:1140–1145CrossRefPubMedPubMedCentral

18.

Dehkharghani S, Bammer R, Straka M et al (2015) Performance and Predictive Value of a User-Independent Platform for CT Perfusion Analysis: Threshold-Derived Automated Systems Outperform Examiner-Driven Approaches in Outcome Prediction of Acute Ischemic Stroke. AJNR Am J Neuroradiol 36:1419–1425CrossRefPubMed

19.

Lansberg MG, Lee J, Christensen S et al (2011) RAPID automated patient selection for reperfusion therapy: a pooled analysis of the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET) and the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) Study. Stroke 42:1608–1614CrossRefPubMedPubMedCentral

20.

Straka M, Albers GW, Bammer R (2010) Real-time diffusion-perfusion mismatch analysis in acute stroke. J Magn Reson Imaging 32:1024–1037CrossRefPubMedPubMedCentral

21.

Kudo K, Sasaki M, Yamada K et al (2010) Differences in CT perfusion maps generated by different commercial software: quantitative analysis by using identical source data of acute stroke patients. Radiology 254:200–209CrossRefPubMed

22.

Klotz E, Konig M (1999) Perfusion measurements of the brain: using dynamic CT for the quantitative assessment of cerebral ischemia in acute stroke. Eur J Radiol 30:170–184CrossRefPubMed

23.

Koenig M, Kraus M, Theek C, Klotz E, Gehlen W, Heuser L (2001) Quantitative assessment of the ischemic brain by means of perfusion-related parameters derived from perfusion CT. Stroke 32:431–437CrossRefPubMed

24.

Abels B, Klotz E, Tomandl BF, Kloska SP, Lell MM (2010) Perfusion CT in acute ischemic stroke: a qualitative and quantitative comparison of deconvolution and maximum slope approach. AJNR Am J Neuroradiol 31:1690–1698CrossRefPubMed

25.

Wahlgren N, Ahmed N, Dávalos A et al (2007) Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. The Lancet 369:275–282CrossRef

26.

Tatu L, Moulin T, Bogousslavsky J, Duvernoy H (1998) Arterial territories of the human brain cerebral hemispheres. Neurology 50:1699–1708CrossRefPubMed

27.

Wintermark M, Flanders AE, Velthuis B et al (2006) Perfusion-CT assessment of infarct core and penumbra receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke. Stroke 37:979–985CrossRefPubMed

28.

Radzina M, Krumina G, Kupcs K, Miglane E (2013) Perfusion computed tomography relative threshold values in definition of acute stroke lesions. Acta Radiol Short Rep 2:2047981613486099

29.

Payabvash S, Oswood MC, Truwit CL, McKinney AM (2015) Acute CT perfusion changes in seizure patients presenting to the emergency department with stroke-like symptoms: correlation with clinical and electroencephalography findings. Clin Radiol 70:1136–1143CrossRefPubMed

30.

Ruiz RL, Quintas S, Largo P et al (2017) Utilidad de la tomografía computarizada cerebral multiparamétrica en el diagnóstico diferencial de patología comicial en el código ictus. Estudio preliminar. Neurologia

31.

Kubiak-Balcerewicz K, Fiszer U, Nagańska E et al (2017) Differentiating Stroke and Seizure in Acute Setting—Perfusion Computed Tomography? Journal of Stroke and Cerebrovascular Diseases 26:1321–1327CrossRefPubMed

32.

Rupprecht S, Schwab M, Fitzek C, Witte OW, Terborg C, Hagemann G (2010) Hemispheric hypoperfusion in postictal paresis mimics early brain ischemia. Epilepsy research 89:355–359CrossRefPubMed

33.

Wiest R, von Bredow F, Schindler K et al (2006) Detection of regional blood perfusion changes in epileptic seizures with dynamic brain perfusion CT—a pilot study. Epilepsy research 72:102–110CrossRefPubMed

34.

Masterson K, Vargas M, Delavelle J (2009) Postictal deficit mimicking stroke: role of perfusion CT. Journal of neuroradiology 36:48–51CrossRef

35.

Szaflarski JP, Rackley AY, Kleindorfer DO et al (2008) Incidence of seizures in the acute phase of stroke: A population-based study. Epilepsia 49:974–981CrossRefPubMedPubMedCentral

Title: Advanced CT for diagnosis of seizure-related stroke mimics
Authors: Friederike Austein
Monika Huhndorf
Johannes Meyne
Helmut Laufs
Olav Jansen
Thomas Lindner
Publication date: 01-05-2018
Publisher: Springer Berlin Heidelberg
Published in: European Radiology / Issue 5/2018
Print ISSN: 0938-7994
Electronic ISSN: 1432-1084
DOI: https://doi.org/10.1007/s00330-017-5174-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Advanced CT for diagnosis of seizure-related stroke mimics

Abstract

Background and purpose

Methods

Results

Conclusion

Key points

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background and purpose

Methods

Results

Conclusion

Key points

Please log in to get access to this content

Other articles of this Issue 5/2018

Imaging putative foetal cerebral blood oxygenation using susceptibility weighted imaging (SWI)

Chemical shift magnetic resonance imaging for distinguishing minimal-fat renal angiomyolipoma from renal cell carcinoma: a meta-analysis

Peripheral nerve diffusion tensor imaging (DTI): normal values and demographic determinants in a cohort of 60 healthy individuals

One-view digital breast tomosynthesis as a stand-alone modality for breast cancer detection: do we need more?

Preoperative sentinel lymph node localization in vulvar cancer: preliminary experience with inguinal intradermal contrast-enhanced ultrasound

A direct comparison of contrast-enhanced ultrasound and dynamic contrast-enhanced magnetic resonance imaging for prostate cancer detection and prediction of aggressiveness