Pseudo-stroke

A large number of studies have been published in recent decades dedicated to the various aspects of the Acute Cerebrovascular Events (ACE). Nonetheless, diagnostics and prevention of strokes are still associated with numerous difficulties and mistakes. Practical knowledge shows that the level of a doctor’s qualification is defined to a great extent; how he can orient himself in the event of an emergency situation, as well as if he can make the right decision under pressure in case of atypical disease course. In such cases a patient’s life is placed in the hands of skilled and trusted medical professionals.

If we talk about an emergency condition then a doctor must solve two diagnostic tasks sequentially:

• Identify whether the disease belongs to the nosologic forms of acute cerebral pathology;
• In the presence of acute cerebral pathology, to determine whether it is caused by an ischemic stroke or a disease with stroke-like course.

One has to differentiate between a stroke and the following pathologic conditions and diseases:

• Cerebral lesions like meningitis, encephalitis, brain abscess, craniocerebral trauma, brain tumor, thrombosis of cerebral veins and sinuses;
• Extracerebral lesions. ОAcute exogenous intoxications (alcohol, food, drug overdose), hypoglycemia and hyperglycemia (with diabetes), acute liver or adrenal insufficiency, azotemia with severe renal failure, a number of acute common infections, acute blood loss, blood diseases and cardiogenic shock.

Differential diagnostics between strokes and various forms of extra cerebral pathologies is most often adequately performed by physicians who provide non-specialized care. According to the data cited by some authors, the listed pathological processes and diseases are erroneously diagnosed as a stroke in 3.6-6.3% of cases.

According to published data in scientific literature, the pseudo stroke is a pathological condition in which patients experienced pronounced focal symptoms that were regarded as clinical manifestations of a stroke. During an autopsy of the brain, no changes were found that could explain these clinical manifestations. Naturally, this formed the reason for the discrepancy between the clinical diagnosis and the diagnosis given after the autopsy.

Main causes of a pseudo stroke

Causative factors are:

• Hemodynamic causes;
• Dysmetabolic causes;
• The reasons that caused the emergence of hypoxia on the basis of the morphological substrate in the form of inferiority of parts of the cerebral vascular system, which occurs as a result of local atherosclerotic lesions, TBI, stroke, neuroinfection, etc.

Decompensating factors are:

• Pneumonia;
• Myocardial infarction;
• Acute or increasing heart or cardiopulmonary insufficiency;
• Renal failure with phenomena of urination or pyelonephritis;
• Pancreatitis;
• Alcohol intoxication;
• Septic conditions;
• Autointoxication in case of severe burns and oncological diseases;
• Diabetes;
• Gastrointestinal bleeding;
• Anemia;
• Pritonitis.

All these factors give rise to the fact that a pseudo stroke, as a rule, is observed in senile and elderly patients.

The reasons for the erroneous statement of the clinical diagnosis are the prevalence of neurological symptoms over the manifestations of somatic pathologies, as well as the atypical course of chronic lung, liver, kidney, cardiovascular system lesions. In addition, the cause of diagnostic errors is most often the lack of reliable anamnestic data, a sharp severity of the patient's condition at the time of hospitalization and the difficulty of a detailed physical examination, due to the fact that 40-60% of patients in this category die within the first 3 days from the time of hospitalization.

The classic description of a slowly developing clinical manifestations of a stroke includes a combination of focal and cerebral symptoms. Nevertheless, upon the interpretation of a number of individual clinical manifestations there are contradictions. Steady progression of the vascular process leads to diagnostic errors in favor of brain tumors, as well as vice versa: apoplectiform manifestation of a number of tumor lesions of the brain that can be mistakenly interpreted as a stroke.

To date, there are no clear criteria for recognizing focal and cerebral symptoms of ischemic stroke. The degree of hypertensive character headaches severity, vomiting, nausea and meningeal signs in modern scientific literature find a different interpretation. There is still no definite specificity in the development of symptoms of topical significance and focal symptoms. The emergence of them in the late stages in the course of the disease, steady progression and the presence of convulsive syndrome significantly complicate the conduct of differential diagnosis.

Currently, the diagnostic activities to establish the true nature of the emergency are somewhat facilitated: the results of MRI or CT can determine whether there are available foci in the brain and pathological neoplasms, or reject a stroke. Nevertheless, only a combination of a careful study of the history, clinical symptoms and course of the disease with paraclinical methods of examination greatly facilitates the differential diagnosis between a stroke and stroke-like brain tumor.

The data published in the modern literature take into consideration that the headache as such cannot be significant for differential diagnosis by a criterion that allows us to distinguish between tumors and stroke. In stroke, meningeal syndrome occurs in the first hours / days after the onset of cerebral and focal symptoms, with a favorable course of the process, it undergoes a rapid reverse development. Patients are often observed with changes in the fundus: the presence of the tortuosity of the vessels, the expansion of veins. In comparison with the tumor there is a clear positive dynamic.

Disorders of the psyche (gross violation of thinking, body regimens, apraxia, decreased criticism and euphoria) appeared in several patients as the first symptomatic manifestation of the disease, but more often followed by a prolonged period of increase in focal symptoms and persistent headache. As a rule, pathological changes in the psyche are more pronounced when the right hemisphere of the brain is affected.

The study of the dynamics of focal symptomatic manifestations development of the pathology showed that the rapid occurrence of hemiparesis is by no means necessary. Development of motor pathology is often delayed for several months or even years - hemiplegia or deep hemiparesis occur only with the weakening of compensatory possibility of collateral blood flow.

Epileptic seizures can often become the first symptom. Some authors consider them late manifestations of the pathology, while others attribute these seizures to the initial signs of the disease. Most often epileptic seizures occur as partial Jacksonian, less common are generalized. It should be noted that paraclinical methods of performing the research should be used for the diagnosis, since the tactics of prolonged observation are not always justified.

See also similar articles on the subject:

• Stroke in menopause
• Drugs for stroke treatment
• Transient ischemic attack

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