STROKE MEDICINE

Mimics and
Chameleons
Sofia Gomes
Lead Nurse in Acute Stroke, Stroke Research and Support Services
sofia.gomes4@nhs.net
Content
Definitions
Common stroke mimics and chameleons
Top tips
WHO definitions
Stroke is an acute neurological deficit lasting > 24 hours attributable to a vascular cause*

TIA is an acute neurological deficit lasting below 24 hours (1960) attributable to a vascular cause** 60-70% TIA <1h30

2004 ANAES describes as a brief neurological defict with vascular origin that lasts less than 1h without proof of
infarction or with negative dwi;
2009 ASA/AHA says it is a neurological deficit caused by ischaemia to brain, spinal or retina with normal DWI. – This
century it doesn’t mention about time, just focus on imaging

Mimic where another condition leads to a similar clinical pattern but a vascular occlusion has not actually occurred

Chameleon Stroke chameleons imitate other diseases due to their tempo of onset (eg, gradual progression or stuttering) or
have symptoms that do not necessarily implicate an arterial territory.
Case 1
32-year-old school teacher presented to ED with visual problems and left side
headache that started 20h ago. Under investigations for diabetes, overweight. Takes
the pill.

She complains she can’t see correctly, but her vision is blurry on assessment. Low-
grade headache, increasing intensity over the last 2h. Her lips feel tingling on the left
side, and her left hand seems weaker and not right.

Mimic?
Chameleon?
Migraine
•Incidence 18% women, 6% men
•Common onset age 5 to 30
•Most usual type is headache without aura *
•About 1/3 accompanied with aura
•Headache with and without aura can be present in same patient
•Episode frequency can vary from several per month to once in a lifetime
•Can develop in later life
•Often positive family history
Migraine with aura
Usually visual (99%), pins and needles (1/3) or aphasia (10%)

Diagnostic criteria
TWO attacks of:
At least ONE of: At least TWO of:
1. Positive and/or negative visual symptoms 1. Homonymous visual and/or unilateral sensory
2. Positive and/or negative sensory symptoms symptoms
3. Dysphasic language disturbance 2. Aura symptom develops gradually over > 5
minutes and/or different aura symptoms occur in
succession over > 5 minutes
3. Each symptom lasts between 5-60 min

International Classification of Headache Disorders

(ICHD-3)
Migraine with aura
TYPICAL AURA WITHOUT
HEADACHE
• Neither accompanied nor followed by headache
of any sort – few patients only
• Present positive and/or negative (visual,
sensory or speech disturbance)
• Often requires further investigations – 1st
episode >40s, prolong deficit (>60min),
negative symptoms = MRI
‘HEMIPLEGIC MIGRAINE’
• Characterized by motor weakness (fully
reversible)
• It may be difficult to distinguish weakness
from sensory loss.
• Motor symptoms generally last less than 72
hours but, in some patients, motor weakness
may persist for weeks = imaging.
International Classification of Headache Disorders
(ICHD-3)
Top tips
Evolution*
Stroke is a thief…

Positive
Duration
symptoms

but Migraine is a magician!

Treatment of Migraine
•Acutely aimed at the Headache
Rehydrate
Specific and non-specific medications
Status migrainosis

•Chronic
Headache prophylaxis
Little out there on aura
Migraine trust
Red flags against migraine
•Maximal symptoms at onset
•Facial weakness
•True hemiparesis
•Non-cortical presentations e.g. pure motor weakness
Recommendations
•Migraine clinical dx – no test
•If in doubt, treat as stroke
•Emergency CT
•Helpful DWI positive expected for any symptoms lasting > 1 hour
•1st episodes of aura always warrants brain imaging
Migraines and Stroke
Strong association
Multifactor – migraines infarction, vasoconstriction syndrome, post partum, genetics
Causes:
Spreading depolarisation
Genetic predisposition
Hormonal
Endothelial dysfunction
Hypercoagulability
Risk persists over time
Take migraine into account as cardiovascular risk factor (QRISK 3 score to improve
standard care)
Hippesley-cox et al, BMJ 2017
Case 2

Mimic?
Chameleon?
Epilepsy
•Disorder of the brain characterized by enduring predisposition to generate epileptic
seizures.

•Define by any of the following:

At least two unprovoked seizures with more than 24h apart
Diagnosis
One seizure with probability of further ones (recurrence risk at least 60% within 10 years)

Fisher et al., Epilepsia 2014; 55: 475-482

Todd’s TOP TIP
•20% of stroke mimics
•The diagnosis is more readily apparent if patients have
recurrent focal motor seizures (which can be subtle).
•Possible hx of epilepsy, although this may not
necessarily have been diagnosed before admission.
•The substrate for the seizure is often an old ischaemic or
haemorrhagic stroke, easily mistaken for an acute stroke
when brain imaging is reviewed.

Anathhanam and Hassan, 2017 Clinical Medicine Journal, 17 (2) 

Seizures with Stroke
EARLY POST-STROKE SEIZURES LATE POST-STROKE SEIZURES
(<7D) (>7D)
•Transient cellular biochemical dysphunction •Epileptogenic gliotic scarring
Increase release of glutamate
Changes membrane, properties,
Ionic imbalance selective neuronal loss, collateral
Breakdown of membrane phospholipids sprouting
Release free fatty acids
•Hemosiderin deposits
•Homeostatic or systemic disturbances
Electrolyte imbalance
Acid-base disturbances
Hyperglycaemia

Pitkanen et al., Epilepsia 2007; 48: 13-20

Treatment of post seizure strokes
EARLY POST-STROKE SEIZURES
•Low risk recurrence (incidence 10-
20%)
•Conditions where considering
secondary preventions: MS, Early
PSS and increased risk of
recurrence (ICH, SAH, SVT)
•Status epilepticus requires urgent
IV therapy and subquent AED Low-
risk
LATE POST STROKE-SEIZURES
•All patients with a first unprovoked late
post stroke seizure are at high risk of
seizure recurrence.
•Renal or hepatic impairment requires
adjustments
•Enzyme-induced AED (carbamazepine,
phenytoin, phenobarbital) – decrease
effect of warfarin and statins – regular
INR and cholesterol level assessments +
dose review
European Stroke J., 2007; 2: 103-115
Case 3
82-year-old woman with new onset of speech difficulty less than 2h ago.
Working as a physio in a home visit when developing the symptoms.
There was no associated weakness, alteration of consciousness, or headache. Per report, she had
experienced a minor ‘‘stroke’’ approximately 2 weeks earlier but had made some improvement.
On arrival alert and orientated. Language examination was remarkable for impaired fluency with the
ability to say only fragments of words. She was able to follow simple midline commands but was
unable to follow complex commands. She was unable to repeat, read, or name objects. There was no
limb weakness or sensory disturbance. Her NIHSS score was 6.
Afebrile, BP142/72 mmHg, BG 4.2.
Tumours
NCCT hyperdense lesion with mass effect
involving the left temporoparietal region
(Figure 1-4, top, arrows).

Follow-up MRI demonstrated an ill-defined

enhancing lesion involving the white matter
and cortex of the left parietal lobe suggestive of
a low-grade neoplasm. (Figure 4-6, bottom
arrows).
Case 4
47 years old female presents to ED complaining about right arm and leg weakness.
PMH asthma as a child and very mild endometriosis with no need of treatment, and
regular vitamins. Recently divorced under stress at work and no relevant family
history.
On examination, she was able to lift her arm, with mild drift but was able to correct
position. She complains about tingling on her arm when we are assessing.
.
Mimic?
Chameleon?
Functional Stroke mimics
•Represent a group with primary psychiatric care needs
•Anxiety and depression are common most common
•Treatment FSM should include:
Phychs review
Cognitive behaviour therapy
Physiotherapy
Case 5
A 75-year-old woman presented to the emergency
unit with a 1-day history of dizziness, balance
impaired, vertigo and vomiting.
She had a history of sick sinus syndrome with a
permanent pacemaker and also of Ménière’s disease.
On examination, she had new atrial fibrillation, an
ataxic gait, nystagmus (fast phase to the left) and
marked unsteadiness.
The initial diagnosis was recurrent Ménière’s disease
and she was prescribed prochlorperazine, but
symptoms not improved.
Mimic?
Chameleon?
Case 6
A 79-year-old man one episode of confusion one
week ago, acting strange since.
Today went for his usual local walk. On his way
home he could not recognise his house, despite
his wife standing at the window waving. He was
brought to the hospital, where he was very
talkative. There were no other symptoms and no
focal neurological deficit
History of paroxysmal atrial fibrillation, not on
anticoagulation, and hypertension.

Mimic?
Chameleon?
Recent right frontal cortical infarction on plain brain CT (arrow).
Case 7
72-year-old right-handed man presented with fluctuating neurological signs.
He had a medical history of hypertension, type 2 diabetes and he was an ex-smoker
of 35 pack-years.
This morning 2 episodes of a sudden onset of the face and arm weakness with a
resolution of symptoms in between.
During your assessment, develops the same symptoms again, lasting 10 min.

Mimic?
Chameleon?
Capsular warning syndrome
•The capsular warning syndrome is one of the most dramatic presentations in stroke
medicine.
•In this striking phenomenon, in situ disease of a single penetrating artery is thought
to cause fluctuating ischaemia and neuronal dysfunction limited to the internal
capsule.
•The early stroke risk is high.
•Many attacks can occur in a short period of time (eg, 24–48 h) leading to suspicions
of seizures or functional disorder in some patients.
Case 7
80yr old female, 5 days ago developed abnormal movements of the left side of her body
Unable to control her left arm and leg and has flailing movements
Her husband has also noticed the left side of her face is affected by 'twitching' movements, including overnight as she sleeps
OE – no visual concerns, normal power and sensation, possible left side face droop, plantars down going

No fever, no weight loss, no recent travel

Hx HTN, breast ca, stroke rt insula – no residual deficit

Mimic?
Chameleon?
Chorea and Hemiballismus
•Chorea typically involves the face, mouth, trunk, and limbs

•Hemiballismus is a hyperkinetic involuntary movement disorder characterized by intermittent,

sudden, violent, involuntary, flinging, or ballistic high amplitude movements involving the ipsilateral
arm and leg caused by dysfunction in the central nervous system of the contralateral side.

THIS PATIENT -> new vs old basal ganglia stroke

Nil acute
Conclusions
•Negative symptoms, maximal at onset – more likely stroke
•Positive symptoms, especially if progressing over minutes- more likely migraine or seizure
•Migraine is a magician – evolution, duration, positive symptoms
•Forced eye deviation towards the hemiparetic side in a patient with altered consciousness =
seizure until proven otherwise
•Fluctuating symptoms with no anatomical correlate – consider functional but beware capsular
warning syndrome.
•TIA and migraines is the most challenge to find diagnosis.
•MRI best and preferable imagining in neurology.
•If in doubt, treat as a stroke and obtain further information and a second opinion!
Thank you
sofia.gomes4@nhs.net
Handouts
TIA
MIMICS CHAMELEONS

Frequent causes of transient Limb shaking TIAs

neurological symptoms that can
mimic TIA include: Capsular warning syndrome
Migraine aura
Seizure
Syncope
Functional or anxiety related
Stroke
MIMICS CHAMELEONS
 TIA Migraine aura Seizure

Onset Sudden Slow progression Rapid spread

Duration Average < 10 min 15-60 mins 2 minutes

Evolution Max at Onset Spreads over minutes Marches over seconds

Visual Blackness, blind Positive, side Rare

Sequential Absent Present Rapidly

History stereotyped prior Often not, or different Suggestive Suggestive

events

History of migraine +/- +