Background: Stroke is a heterogeneous, catastrophic disease. A comprehensive clinical analysis of ischemic stroke (IS) risk factors and outcomes is crucial for optimum management in resource-poor settings.Methods: A prospective cross-sectional study of acute cerebrovascular disease (ACVD) involving 592 patients was conducted in a tertiary care center in Sri Lanka from November 2018 to May 2019. We aimed to describe the ACVD subtypes and the relationship of IS subtypes and subtype-categories (as defined by the Oxfordshire Community Stroke Project clinical classification) with risk factors, severity, and outcome.Results: The majority (63.3%) had IS. Partial anterior circulation syndromes (PACS), total anterior circulation syndrome (TACS), posterior circulation syndromes (POCS), and lacunar syndromes (LACS) accounted for 102 (29.7%), 58 (16.9%), 88 (25.7%) and 95 (27.7%) of the cases, respectively. The most common PACS sub-category was higher-cerebral-dysfunction-with-homonymous-hemianopia (HCD+HH,39 cases;38.2%). Cerebellar-signs-without-long-tract-signs (CS-LTS) sub-category constituted the highest among POCS (47 cases; 53.4%). The leading sub-category within LACS was pure-motor (PM) strokes (43 cases; 45.3%).Patients aged ≥50 years (adjusted-OR [AOR]2.439; 95%CI,1.163-5.116;P=.018), IHD(AOR 2.520; 95%CI,1.347-4.713; P=.004) and BMI>23kg/m2(AOR 2.607; 95% CI,1.420-4.784; P=.002) were 2.5 times more likely to associate with TACS. Patients with a history of TIA (AOR 1.910; 95%CI,1.036-3.524; P=.038) and arrhythmias (AOR 5.933; 95%CI,3.294-10.684; P<.001) were 1.9 and 5.9 times more likely to be associated with POCS respectively. Those with hypertension were 2.3 times more likely to associate with LACS (AOR 2.233; 95%CI,1.270-3.926; P=.005).NIHSS(P<.001), mRS on admission (P=.001) and in 3 months (P<.001), deaths during hospital stay (P=.003) and within 28 days (P<.001) had a stronger relationship with individual stroke subtypes.Conclusion: The comparative risk of different IS subtypes depends on different risk factors. The findings of this study demonstrate that sub-categories within each stroke subtype may behave independently with regard to risk factors and outcomes, thus warranting the need for individual assessment. Ethn Dis. 2021;31(4):509-518; doi:10.18865/ed.31.4.509
Background: A presentation of upper motor and lower motor clinical signs without sensory impairment may suggest Amyotrophic lateral sclerosis, especially when it involves limbs and bulbar regions. However, co-existence of two or more unrelated pathologies can give rise to a clinical picture similar to Amyotrophic lateral sclerosis.
Case presentation: A 45 year old lady presented with slowly progressive right upper limb weakness for 6 months and mild left upper limb weakness for 2 months associated with muscle twitching. Her family members have noticed a change in character of her speech for few weeks. She couldn’t recall a radicular pain at any given time. On examination, her right deltoid was wasted with numerous fasciculations over right proximal muscles. Right shoulder movements were weak. Her left deltoid was slightly wasted and fasciculations were appreciated. Her both biceps and supinator jerks were normal with exaggerated triceps jerks and positive Hoffman sign. Sensory and proprioception examinations were unremarkable. Both lower limbs were hypertonic with exaggerated knee and ankle jerks. Ankle clonus was absent and plantar responses were equivocal. Her tongue was deviated to right side with fascicuations and wasting of right side. Palatal movements and Jaw jerk were normal. She was clinically diagnosed as possible amyotrophic lateral sclerosis. Electromyography showed denervation changes in deltoids and biceps with right predominance and right genioglossus muscle too showed denervation changes. Magnetic resonant imaging of brain stem was undertaken especially because her tongue wasting and fasciculations were unilateral and it showed a right sided hypoglossal schwannoma. Magnetic resonant imaging of cervical spine revealed degenerative disk disease with mild cord compression and exit foramina narrowing at multiple levels.
Conclusions: Pure motor symptoms with a mixture of upper motor and lower motor signs may suggest a clinical diagnosis of Amyotrophic lateral sclerosis. However, when there are rare manifestations of a relatively common disease, such as unilateral tongue involvement as in the above scenario, a higher degree of clinical suspicion is needed to think of a dual pathology.
Keywords: Hypoglossal schwannoma, cervical myeloradiculopathy, Amyotrophic lateral sclerosis, dual pathology.
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