ESO Educational Webinar report: Headache associated with stroke mimics

When to suspect a stroke mimic with patients with headache and focal neurological deficits? Are there any features in the patient history, clinical presentation, or acute imaging that could swift the diagnosis towards a mimic instead of ischaemic stroke? Are there any other investigations that could help? And what are the clinical entities presenting with headache that should be considered in differential diagnosis of acute stroke?

These questions familiar to any stroke physician working with acute patients were addressed in the latest ESO Educational Webinar entitled “Headache associated with stroke mimics” on 10 December. The webinar included presentations from Dr. Bogdan Ciopleias and Prof. Anita Arsovska, followed by a discussion moderated by Dr. Xabier Urra and Dr. Marieta Peycheva. The recording of the webinar is available for all ESO members on the eSTEP platform.

Dr. Ciopleias opened with a case presentation of a young patient with recurrent episodes of intense headache, hemiparesis, and aphasia. After initial suspicion of ischaemic stroke, it was lumbar puncture, clinical follow-up, and normal MRI imaging that revealed the correct diagnosis of a HaNDL (transient Headache and Neurological Deficits with cerebrospinal fluid Lymphocytosis) syndrome. The HaNDL syndrome is a monophasic condition with single or recurrent episodes of migraine-like headache and a focal neurological deficit lasting more than 4 hours with CSF lymphocytosis (>15 white cells per µl) but otherwise negative work-up.¹ Patients recover fully, and the condition rarely recurs after the self-limiting symptomatic period.

Prof. Arsovska followed with a comprehensive talk on disorders presenting with headache and mimicking acute stroke, such as migraine with aura, hemiplegic migraine, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, brain tumours, idiopathic intracranial hypertension, and HaNDL syndrome. She described the typical clinical course of the disorders and gave insight into how they can be suspected based on imaging findings. Often more extensive imaging than plain CT, if available, can help in differential diagnosis. Moreover, there are clinical scales intended to aid in differentiating a mimic from stroke. The scales, such as FABS, simplified FABS, Telestroke mimic score, Khan score, and Santa Maria Nuova scale consider a combination of features, including age, presence of atrial fibrillation, blood pressure, symptom pattern, and history of epilepsy or migraine that either increase or reduce the likelihood of stroke. Prof. Arsovska emphasised that the scales can aid in correct diagnosis but should be used together with imaging and other available clinical data.

It was acknowledged during the discussion that the diagnosis of the conditions mimicking stroke can be difficult, especially in the time pressure of an acute stroke code alarm with limited available investigations. Despite these challenges, the experts encouraged to aim at the correct diagnosis to prevent potentially harmful investigations and treatments, psychological harm, and possible long-term consequences for work and driving.

Not an ESO member yet? Become a member to access the eSTEP platform to review all ESO Educational Webinars and further stroke related educational content.

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References:

1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul;33(9):629-808. doi: 10.1177/0333102413485658.