Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina.
J Emerg Med. 2020 Mar;58(3):439-443. doi: 10.1016/j.jemermed.2019.12.019. Epub 2020 Mar 18.
Prompt and effective management of acute ischemic stroke in the emergency setting requires a high level of suspicion and accurate diagnosis. Conversely, identifying stroke mimics can be challenging, given the similarity of their clinical symptomatology, the necessary rapid assessment and triage, and the overall frenetic pace inherent in the goal of rapid thrombolysis ("time is brain").
We describe a case that involves an elderly patient with acute hemiplegia and dysarthria. Given these concerning symptoms, and multiple preexisting cerebrovascular risk factors (including paroxysmal atrial fibrillation), a "stroke alert" was issued. Imaging was negative for infarct and she was ultimately diagnosed with hemiplegic migraine based on her symptoms and impressive findings on a novel magnetic resonance sequence called arterial spin labeled (ASL) perfusion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Identifying a nonischemic etiology in a presumed stroke patient, while often difficult, can obviate unnecessary treatment, improve patient care, and promote appropriate resource allocation. As imaging and treatment of cerebrovascular disease advances, the optimization of multidisciplinary care should incorporate neuroradiologists informing and availing their clinical colleagues of applications of an ever-expanding imaging armamentarium. This case is an excellent example of both a common challenging stroke mimic and the potential benefits of ASL perfusion imaging in refining and expediting accurate diagnosis. In addition, it serves as a more general introduction to the particular strengths of this noninvasive, noncontrast magnetic resonance technique, which can be employed to assess varied emergent neuropathology.
在急诊环境中，及时有效地管理急性缺血性脑卒中需要高度怀疑和准确诊断。然而，由于其临床症状相似，需要快速评估和分诊，以及快速溶栓（“时间就是大脑”）的总体狂热节奏，因此识别中风模拟物可能具有挑战性。
我们描述了一位老年患者急性偏瘫和构音障碍的病例。鉴于这些令人担忧的症状，以及多种先前存在的脑血管风险因素（包括阵发性心房颤动），发出了“中风警报”。影像学检查未发现梗死，最终根据她的症状和一种新的磁共振序列（称为动脉自旋标记（ASL）灌注）的显著发现诊断为偏瘫性偏头痛。
为什么急诊医生应该注意这一点？：在疑似中风患者中识别非缺血性病因，虽然通常很困难，但可以避免不必要的治疗，改善患者护理，并促进适当的资源分配。随着脑血管病的影像学和治疗的进步，多学科护理的优化应包括神经放射科医生告知并为其临床同事提供不断扩展的影像学设备的应用。该病例是常见的具有挑战性的中风模拟物的一个很好的例子，也是 ASL 灌注成像在完善和加速准确诊断方面的潜在益处的一个很好的例子。此外，它还更广泛地介绍了这种非侵入性、非对比磁共振技术的特殊优势，可用于评估各种紧急神经病理学。
