Embolic strokes without focality

[Phantom Spike]

I've recently seen a lot of patients for "confusion", who, on more detailed history-taking, apparently have had a sudden onset of what I would call dementia-like symptoms. When you talk to them, they are disoriented to year, place and often situation, and have short term memory loss (inability to recall objects, etc). In some cases they are slow to respond, and have mild attentional deficits, but no focality at all. No drift, no facial droop, no dysarthria, no neglect. Often the cognitive symptoms are very subtle.

Without a history, I would have chalked their MMSE down to a chronic degenerative brain syndrome (i.e., dementia), but the family insists this is "not like them". I used to be skeptical, assuming the family simply didn't realize how bad the patient really was at baseline and that there was some toxic-metabolic cause underlying the apparent sudden worsening, but in many of these cases the brain MRI diffusion sequences ended up revealing many tiny areas of hyperintensity, usually in the posterior circulation territory, presumably embolic emboli (that would likely never be picked up on any other sequence).

I don't recall this particular phenomenon being part of conventional teaching. Have other practitioners on this board noted similiar cases? Until I started noticing this trend, I used to think that the "anything could be a stroke" mindset was simplistic, but now, I guess that really is true.

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[buckley]

Hmmm...we were taught that before you attribute dementia to a chronic degenerative process, you must rule out stroke. it does present as personality changes and memory loss and it can be a "chronic" thing where there are raining emboli and flooding atherosclerosis.

 

[neglect]

I'm a bit unsure about this case. I don't get MRIs for acute onset confusion in the setting of dementia, and a few DWI dots don't explain the cognitive profile of AD. Better to focus on the medical issues.

 

[Phantom Spike]

I'm a bit unsure about this case. I don't get MRIs for acute onset confusion in the setting of dementia, and a few DWI dots don't explain the cognitive profile of AD. Better to focus on the medical issues.

Most of the time, the MRIs have been ordered by the admitting team before I even see the patient. As for the prior diagnosis of dementia, the family almost always insists that the patient was "sharp as a tack" before "this" happened. In some of these cases, the patient was recovering from a procedure, usually a cardiac catheterization, carotid stenting or an endarterectomy. Therefore, the sedatives, anesthetics and narcotics may be to blame. However, this is not always the case. The medical workup (basic labs, ammonia, chest X-ray, blood and urine cultures) are unrevealing. And you're left with the MRI findings suggesting a shower of emboli.

The strangest case on these lines that I saw was a woman in her sixties, admitted because she "just didn't feel right" and "thought she had a stroke". Of course, she couldn't be more specific. She had a completely normal neurological exam, was afebrile, lucid, oriented with perfect recall and a perfect MMSE. She appeared to be slightly anxious and paranoid and somewhat distractable, but for all I knew, that was just her personality. But an MRI was ordered and sure enough, she had a small high right parietal DWI hyperintensity. Now was that the cause for her symptoms? She had a complete workup after that of course; carotid dopplers, a 2D echo, and was placed on Aggrenox. Should the MRI never have been ordered?

Cases like these make all your localization skills seem pointless. Might as well get an MRI for every vague symptom or forgotten word.

 

[danielmd06]

I've seen cases of elderly patients that have a baseline mild dementia (arguably undetectable to family members) and then a small stroke radically worsens their cognition.

It is also possible that it could be a primary angiitis of the central nervous system, or a drug-induced reversible cerebral vasoconstriction symdrome (if the mental function improves).

Has the patient had an ESR or an LP? PACNS would ordinarily have an elevated opening pressure, protein and a lymphocytic pleocytosis.

 

[exgatr]

they could be areas of watershed infarct from hypotension. i've seen that a few times.

 

[neglect]

Most of the time, the MRIs have been ordered by the admitting team before I even see the patient. As for the prior diagnosis of dementia, the family almost always insists that the patient was "sharp as a tack" before "this" happened. In some of these cases, the patient was recovering from a procedure, usually a cardiac catheterization, carotid stenting or an endarterectomy. Therefore, the sedatives, anesthetics and narcotics may be to blame. However, this is not always the case. The medical workup (basic labs, ammonia, chest X-ray, blood and urine cultures) are unrevealing. And you're left with the MRI findings suggesting a shower of emboli.

Oh sure, if they've had a tube stuck in their large arteries or a plaque dug out of the carotid - I think we can expect a shower of emboli. What else explains Bill Clinton's frontal lobe these days? Then a useless MRI will confirm what we already know: messing around with large vessels sends micro and macro emboli to the brain.

The strangest case on these lines that I saw was a woman in her sixties, admitted because she "just didn't feel right" and "thought she had a stroke". Of course, she couldn't be more specific. She had a completely normal neurological exam, was afebrile, lucid, oriented with perfect recall and a perfect MMSE. She appeared to be slightly anxious and paranoid and somewhat distractable, but for all I knew, that was just her personality. But an MRI was ordered and sure enough, she had a small high right parietal DWI hyperintensity. Now was that the cause for her symptoms? She had a complete workup after that of course; carotid dopplers, a 2D echo, and was placed on Aggrenox. Should the MRI never have been ordered?

Cases like these make all your localization skills seem pointless. Might as well get an MRI for every vague symptom or forgotten word.

1. Was it black on ADC?
2. Acute confusional state can be secondary to a stroke, but it is rare. The last one I saw was a left caudate stroke giving rise to what appeared to be memory dysfunction with a mild dysfluency.
3. Would you obtain MRI's on 1000 patients with the same presentation? I would not. And I don't. When the primary service does, I think their yield is low.
4. Stroke is a common problem. The brain is very effective at catching clots.