Rare causes of stroke [PDF]

Haemorrhage into tumor/metastasis. ◇ Coagulopathies. ➢ Blood disorders (platelets, hemophilia, leucemias). ➢ DIC.

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Idea Transcript


Joint Annual Meeting SNG|SSN Basel, October 10th, 2012

Rare Causes of Stroke

PD Dr Patrik Michel Neurology Service, CHUV

Unité Cérébrovasculaire

How rare are « rare » ischemic strokes ? N=2612 consecutive acute strokes 2003-2011 Rare causes PFO Missing

Dissections Multiple Lacunar

4%

5% 5%

data 3% 3%

30%

Cardioembolic

13% 13%

10% 14%

Atherosclerosis •stenosis)

Unknown «Likely athero» Modified TOAST classification, standardized workup Source:

Michel & Eskandari, unpublished

Rare stroke syndromes Overview 1. Vasculitis 2. Hypercoagulability and oncologic 3. Drug related stroke 4. Migraine, vasospasms, pregancy 5. Rare cardiac causes 6. Genetic diseases 7. Other non-inflammatory vasculopathies 8. Unusual causes of ICH

Primary systemic vasculitides ‹

Giant cell ¾ Temporal arteritis ¾ 7DND\DVX¶V arteritis

‹

Necrotizing ¾ Polyarteritis nodosa ¾ Churg-Strauss syndrome

‹

Granulomatous ¾ :HJHQHU¶V granulomatosis ¾ Lymphomatoid granulomatosis

‹

With prominent eye involvement ¾ ¾ ¾ ¾ ¾

6XVDF¶V syndrome &RJDQ¶V syndrome (also necrotizing) Vogt-Koyanagi-Harada syndrome (VKH) Eales¶UHWLQRSDWK\ Acute posterior multifocal placoid pigment epitheliopathy

Quiz : 76 y.o. man

‹

'RHVQ¶W see the doctor Now : acute pure left hemiparesis NIHSS fluctuating between 8 and 1 CT/CT-perfusion : normal

‹

Diagnosis: lacunar warning syndrome

‹ ‹ ‹

Æ Hyperacute CT: normal Æ IV thrombolysis at 2h25min. ‹

Acute CT-angiography :

IPP2819339

76 yo man, lacunar warning syndrome Pre-thrombolysis CTA

2819339

Segmental narrowing both vertebrals

CTA: A. Fumeaux

Duplex and temporal arteritis : arterial wall thickening

Duplex: L.Hirt

Halo

Segmental narrowing

MRI and temporal arteritis : arterial wall thickening

T1- temporal art.

T1-Gado-ophtalmic

Temporal artery biopsy

IPP2819339

Histology: Dr I. Letanovic, CHUV

Giant cell: Temporal arteritis ‹ ‹ ‹

Is rare below 60 years Continuum TA - PMR If stroke (about 3-7%) : ¾ Mainly from extracranial vertebral arteritis ¾ May occur after corticosteroid have been started

‹

Diagnosis : ¾ Sedimentation rate may be normal (15%) ¾ Temporal artery Duplex/CTA/MRA: moderately helpful ¾ Biopsy: ‡ Take long segment, consider contralateral temporal artery ‡ Corticosteroids GRQ¶W negativize biopsy for 7-14 days

1. Vasculitis as potential cause of stroke

‹

Primary systemic vasculitides

‹

Vasculitides secondary to systemic disease

‹

Isolated vasculitis of the CNS

Giant cell: 7DND\DVX¶V arteritis ‹

‹

Extracranial vaculitis: aortic arch and main arterial trunks, descending aorta and renal arteries Clinical: ¾ ¾ ¾ ¾ ¾

‹

Pulselessness/claudication/paraesthesias upper extremities CNS: dizziness, headache, syncope Systemic symptoms Strokes (20-30%): ischaemic or haemorrhagic ESR in most, renal hypertension

Diagnosis: major and minor criteria Takayasu Japanese J Ophtal 1905. Diagnostic criteria: Arend 1990

Quiz : 26 y.o. lady, good health ‹

History : since 1 month : ¾ ³6PRNH\´YLVLRQ ¾ Memory problems ¾ Unstable gait ¾ One episode of diplopia ¾ Mild posterior headache

‹

Exam: ¾ Attentional problems ¾ Mild bilateral corticospinal and cerebellar signs ¾ Left hypoaccousis

Primary vasculitides with eye/ear involvement ‹ ‹ ‹

‹ ‹

&RJDQ¶V syndrome 6XVDF¶V syndrome Vogt-Koyanagi-Harada syndrome Eales retinopathy Acute posterior multifocal placoid pigment epitheliopathy

26 y.o. lady: MRI

T2W

Diffusion (DTI)

FLAIR

6XVDF¶VV\QGURPHUHWLQDOILQGLQJV

68753

68753

Indocyanide angiography Contrast leak

Fluoro-angiography Arterial narrowings Venous obstructions

Courtesy : Dr JA Pournaras, Lausanne eye hospital

Susac's syndrome Retino-cochleo-cerebral arteriolopathy ‹

Triade: ¾ Small cortical and subcortical strokes ¾ Retinal branch occlusion ¾ Infarctions of cochlea (Æ neurosensory hearing loss)

‹

‹

Monophasic disease with or without preceeding specific infections Differential Dx: multiple sclerosis

Susac Neurology 1979 and 2003; Barker JNNP 1999

Cogan's syndrome ‹

Triade: ¾ CNS-vasculitis ¾ Keratitis ¾ Deafness

‹

Rare: ¾ Headaches, encephalopathy, lymphocytic meningitis, encephalopathy, seizures ¾ Sinus vein thrombosis ¾ Peripheral or cranial neuropathy ¾ Aortitis, aortic insufficiency ¾ GI hemorrhage, hepatospleno, lympadenopathy

DG Cogan 1945

Vogt-Koyanagi-Harada syndrome (VKH) ‹

Triade: ¾ CNS&meningeal symptoms ¾ Bilateral uveitis ¾ Hair changes (poliosis, alopecia)

‹

Other neurological manifestations (rare) ¾ Encephalopathy, coma ¾ Seizures ¾ Cranial nerve palsy (V-VIII)

‹

4 stages: ¾ ¾ ¾ ¾

1) Prodromal (days): meningeal&neurologic manifestations 2) Uveitic (weeks): posterior-> anterior uvea 3) Convalescent (months) : hair/skin changes 4) Chronic recurrent stage Vogt 1906, Koyanagi 1929, Harada 1926

Vasculitides secondary to systemic disease ‹ ‹ ‹ ‹

‹ ‹ ‹ ‹ ‹

Systemic Lupus erythemtodes (SLE) 6M|JUHQ¶V syndrome %HKoHW¶V disease Sarcoidosis Rheumtoid polyarthritis Scleroderma Mixed connective tissue disease Dermatomyositis Ulcerative colitis/&URKQ¶V disease

Systemic lupus erythematodes Mechanisms of stroke ‹

Ischaemic ¾ Libman-Sachs endocarditis ¾ Hypercoagulability: antiphopholipids, cytokines ? ¾ Cerebral vasculopathy/vasculitis

‹ ‹

Haemorrhagic Cerebral venous thrombosis ¾ Hypercoagulability: antiphopholipids

Other vasculitides secondary to systemic disease ¾ ¾ ¾ ¾ ¾

SLE 6M|JUHQ¶V syndrome %HKoHW¶V disease Sarcoidosis Rheumatoid polyarthritis

¾ Scleroderma, MCTD ¾ Dermatomyositis ¾ Ulcerative colitis/&URKQ¶V disease ‹ ‹

11 criteria. Stroke, venous thrombosis Dry eyes/mouth, ANA+ (-> SSA/SSB+) Oral/genital ulcers 3x/y, eye, skin Respiratory problems, liver, skin, uveitis 4 or 7 criteria (morning stiffness >1h, 3 joints, hand joints, rheumatoid nodules) ¾ Skin, multiples autoimmune ¾ Myopathy, dermatitis (extensor-side of joints/eye-lids) ¾ GI symptoms, malabsorption ¾ ¾ ¾ ¾ ¾

Most can develop have CNS and/or PNS vasculitis Most can have other immunological disorders affecting near-neurological structures (autoimmune meningitis, uveitis, nerve compression, myositis)

Quiz : 61 y.o. old woman ‹ ‹ ‹ ‹ ‹

Hypertension, smoking Controlled Basedow Recent removal of a skin kyste (neck) Now : 3 days of fluctuating confusion, aphasia? On exam: ¾ Inattentive, sometimes crying ¾ Fluent aphasia, major apraxia ¾ Mild right corticospinal signs

IPP507240

61 y.o. woman : MRI

507240

DWI

T1-Gadolinium

61 y.o. woman : work-up ‹ ‹ ‹ ‹ ‹ ‹ ‹

Blood normal CRP and sed. rate normal ETT & ETO : normal Ophta : normal retina No cancer Homocysteine-, APLALumbar punctuer: ¾ 70 leukocytes (PMN)

IPP507240

Angio: Dr JB Zerlauth, CHUV

IPP507240

Isolated (primary) vasculitis of the CNS ‹ ‹

Rare, difficult diagnosis Presentation: very variable ! Recurrences/progression of ¾ Cognitive problems/confusion ¾ Focal symptoms and signs ¾ Headaches

‹

Diagnosis: no gold standard ¾ Multiple lesions on MRI (80%), leptomeningeal enhancement (60%) ¾ Abnormal LP (50%-90%) ¾ Segmental narrowing on DS-angiography (50-80%, DDx: spasms, emboli) ¾ Brain/meningeal biopsy (80%) ¾ Retinal fluorescein angiography ¾ Rule out endocarditis, toxics/drugs, malignancy etc.

Infectious and postinfectious vasculitis/vasculopathy ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹ ‹

Meningovascular syphilis Neuroborreliosis (Lyme disease) Tuberculosis and mycosis Bacterial meningitis with strokes Neurocysticercosis VZV-related; CMV and herpes related Chlamydia pneumoniae/Mycoplasma HIV: hetereogenous mechanisms Hepatitis C and mixed cryoglobulinemia

Meningovascular syphilis   ‹ ‹

Any vessel affected, often cognitive problems Diagnosis ¾ Clinical & ¾ Pleocytosis on LP & ¾ Elevated IgG or IgM CSF-index for treponema IgG-CSF/IgG-Serum Albumine-CSF/Albumine-Serum

‹

Mechanisms of stroke in symphilis: ¾ Meningeal vasculitis ¾ Marantic endocarditis ¾ Aortic dissection

VZV related vasculopathy ‹

‹ ‹

‹

Adults: 2-6 weeks after shingles mainly of the trigeminal nerve Children: 1-3 months after varicella = chickenpox Pathogenesis: controversial (infectious vs. immunologic) Clinical ¾ Ipsilateral deep or superficial MCA-stroke ¾ Rarer: disseminated CNS-vasculopathy (mainly if immunosuppressed) ¾ Very rare: optic nerve ischaemia, retinal necrosis

2. Hypercoagulable causes of stroke ‹ ‹ ‹ ‹

‹

‹ ‹

Antiphospholipid antibody syndrome Hyperhomocysteinaemia Hyperviscosity syndromes Disseminated intravascular coagulation (DIC) and Moschcowitz syndrome (thrombotic thrombocytopenic purpura) Disorders of the coagulation cascade Mixed cryoglobulinemia (hepatitis C) Paraneoplastic (intestinal, lung, gynecologic)

Quiz: 30 y.o. man ‹

‹

2003: minor right MCA stroke. PFO & ASIA, smoking, cholesterol Æ PFO-closure 2230097

CTP 281 min. ‹

‹

2230097

IRM à 12 h

2005: massive right MCA stroke Æ ivthrombolysis at ¶ No more R-L shunt, still cholesterol, smoking &73j¶T-occlusion carotid No atherosclerosis

Hyperhomocysteinaemia ‹

Causes ¾ Genetic: MTHFR (rarely cystathionine-beta-synthase or methionine synthase deficiency* (skin-Bx!)

¾ Genetic childhood form: also marfanoid features, mental retardation, ectopia lentis ¾ Nutrition/malabsorption: B6, B12 and folic acid deficiency ‹

Clinical: ¾ Linear increase of stroke and coronary risk with serum levels ¾ Incresed risk of venous thrombosis

‹

Treatment (folic acid, B6, B12): ¾ No clear benefits for stroke prevention ¾ Individual cases may benefit* Vitamin stroke trials: Toole/VISP: JAMA 2004; VITATOP, Lancet Neurol 2010 *Novy, Thromb Haemostas 2010

Antiphospolipid antibody syndrome (APLS) Diagnostic criteria (1 clinical & 1 laboratory) ‹

Clinical criteria ¾ Vascular thrombosis (arterial or venous, any tissue or organ) ¾ Otherwise unexplained abortus ‡ 1 death fetus >10th week, or ‡ 1 premeature birth

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