UMEM Educational Pearls

One study found that the top 4 stroke mimics confused for a true stroke are: 1) Unrecognized seizure with post-ictal phase 2) Systemic infections 3) Brain tumor 4) Metabolic disturbances Complex migraine, specifically hemiplegic migraine, is also a common stroke mimic. This diagnosis is especially difficult to make on initial presentation and should be a diagnosis of exclusion. The hemiparesis associated with the migraine can actually outlast the actual headache. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Archives of Neurology. 1995;52:1119-1122.

*Hormone-related migraine headaches are largely related to changes in levels of estrone glucuronide (EIG). *Studies have shown that in addition to an increase in symptoms for female migraneurs during the menstrual phase (during first 3 days of menses), there are also 3 distinct midcyle (around day 14) phases during which migraines are most prevalent. They are: 1) Late follicular phase (LF) (rapid rise in estrodiol level) 2) Early follicular 1 phase (rapid drop in estrodiol level) 3) Early follicular 2 phase (rapid rise in progesterone level) American Headache Society 49th Annual Scientific Meeting: Abstract 150. June 7-10, 2007.

Learn the Lingo for Stroke Manangement: Patients with acute stroke due to a carotid artery thrombotic lesion that then embolizes to a cerebrovascular artery, have two problems that can be addressed with one coordinated intervention. * "Triple Play" = (1) Carotid artery lesion stenting followed by (2) retrieval of the embolic clot from the cerebrovascular artery via the Merci device followed by (3) intra-arterial tPA (the latter prevents complications that could result from removal of embolic clot). * "Double Play" = (1) Retrieval of the clot from the cerebrovascular artery via the Merci device followed by (2) intra-arterial tPA. Merci Device information: http://www.concentric-medical.com/products_retrieval.html

Diagnostic Criteria for Migraine Headaches: * Migraine w/o aura- A. At least five headache attacks lasting 4 - 72 hours, with at least two of the four following characteristics: 1. Unilateral location. 2. Pulsating quality. 3. Moderate or severe intensity (inhibits or prohibits dailyactivities). 4. Aggravated by walking stairs or similar routine physical activity. B. During headache, at least one of the two following symptoms occur: 1. Phonophobia and photophobia. 2. Nausea and/or vomiting. * Migraine w/ aura (remember: aura is not always visual) - A. At least two attacks with at least three of the following: 1. One or more fully reversible aura symptoms indicating focal cerebralcortical and/or brain stem functions. 2. At least one aura symptom develops gradually over more than four minutes,or two or more symptoms occur insuccession. 3. No aura symptom lasts more than 60 minutes; if more than one aura symptomis present, accepted duration is proportionally increased. 4. Headache follows aura with free interval of at least 60 minutes (it mayalso simultaneously begin with the aura). B. At least one of the following aura features establishes a diagnosis ofmigraine with typical aura: 1. Homonymous visual disturbance. 2. Unilateral paresthesias and/or numbness. 3. Unilateral weakness. 4. Aphasia or unclassifiable speech difficulty. Headache 44(5):426-435, 2004. Headache classification committee of the IHS. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988 8: 1-96.