Stroke warning syndrome

Sales, Carmela; Calma, Aicee

doi:10.1016/j.clineuro.2022.107120

Cited by 6 publications

(4 citation statements)

References 56 publications

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“…The history we describe is classical of capsular warning syndrome (CWS). Capsular warning syndrome is a rare clinical syndrome characterized by recurrent and frequent transient episodes of focal neurological deficits with a high risk of infarction ( 10 ). The exact physiological mechanism of CWS remains unclear, but it is most commonly believed to be a result of hemodynamic insufficiency in diseased small penetrating vessels ( 11 ).…”

Section: Discussionmentioning

confidence: 99%

Case report: Concurrent low-volume subdural hematoma and ipsilateral ischemic stroke presenting as capsular warning syndrome: a complex case with anticoagulation dilemma and dual pathology

Strahnen,

Stathi,

Beck

et al. 2024

Front. Neurol.

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BackgroundThe simultaneous emergence of low-volume subdural hematoma and ipsilateral ischemic stroke in an atrial fibrillation patient who is under anticoagulation therapy is a rare and intricate clinical case. This report accentuates the diagnostic and treatment complexities associated with these consecutive neurological conditions.Case presentationAn 83 years-old male patient initially presented with acute dyspnea, raising the suspicion of pulmonary embolism. After exclusion of pulmonary embolism through CT angiography, the patient experienced a sudden onset of left-sided hemiparesis without prior history of head trauma but with chronic intake of apixaban due to atrial fibrillation. Subsequent cranial CT tomography revealed a small right parietal subdural hematoma. After reversal of the anticoagulation therapy, surgical evacuation of the subdural hematoma was successfully performed. However, in the postoperative period, the patient developed new neurological symptoms that could not be explained by the reduced size of the subdural hematoma on a follow-up CT scan. Cranial MRI revealed the coexistence of acute ischemic stroke in the right corona radiata. The recent surgical procedure precluded guideline-recommended stroke treatment.DiscussionThis case underscores the complexities of diagnosing and treating concomitant small volume subdural hematoma and ischemic stroke, especially if the latter occurs in the corona radiata resulting in fluctuating symptoms known as “capsular warning syndrome.” Reversal and secondary discontinuation of anticoagulant therapy for surgical intervention highlight the inherent risk of thrombotic events in anticoagulated patients. The development of tailored treatment strategies requires a multidisciplinary approach, and further research and guidelines are required in similar complex scenarios.ConclusionThe presence of both a small subdural hematoma and an ipsilateral ischemic stroke presenting as capsular warning syndrome in an anticoagulated patient highlights the intricacy of their care. This case calls for a comprehensive and collaborative strategy to address complicated clinical scenarios.

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Section: Discussionmentioning

confidence: 99%

Case report: Concurrent low-volume subdural hematoma and ipsilateral ischemic stroke presenting as capsular warning syndrome: a complex case with anticoagulation dilemma and dual pathology

Strahnen,

Stathi,

Beck

et al. 2024

Front. Neurol.

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“…It has been reported that the initial impression of BP may be incorrect with a misdiagnosis rate ranging from 0.8% to 20%, mostly occurring within 90 days after initial diagnosis, especially in older individuals and patients with DM . Because prodromal repeated transient ischemic attack of an impending stroke is sometimes indistinguishable from BP, we excluded 20 (0.4%) of individuals who had a stroke within 1 month after the onset of BP. Moreover, systemic corticosteroids may not be administered despite a correct diagnosis of BP being made if patients have an underlying illness, such as refractory hypertension, poor diabetes control, or gastrointestinal disease, which deters clinicians from prescribing systemic corticosteroids.…”

Section: Discussionmentioning

confidence: 99%

Association of Influenza Vaccination With Risk of Bell Palsy Among Older Adults in Taiwan

Wei

Wang

et al. 2023

JAMA Otolaryngol Head Neck Surg

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ImportanceAnnual administration of the influenza vaccine (fluVc) is currently the most effective method of preventing the influenza virus in older adults. However, half of adults older than 65 years remain unvaccinated in Taiwan, possibly because of concern about adverse events, such as Bell palsy (BP). Currently, studies on the association between fluVc and risk of BP are inconsistent.ObjectiveTo determine whether the incidence of BP increases following fluVc in older adults.Design, Setting, and ParticipantsA self-controlled case series study design was used. Days 1 through 7, days 8 through 14, days 15 through 30, and days 31 through 60 following fluVc were identified as risk intervals, and days 61 through 180 were considered the control interval. A total of 4367 vaccinated individuals aged 65 years or older who developed BP within 6 months following fluVc were enrolled. Population-based retrospective claims data were obtained between 2010 and 2017; data were analyzed from April 2022 through September 2022.ExposureGovernment-funded seasonal fluVc.Main Outcomes and MeasuresThe outcome of interest was BP onset in risk intervals compared with control intervals. Three or more consecutive diagnoses of BP within 60 days following fluVc were used as the definition of a patient with BP. Poisson regression was used to analyze the incidence rate ratio (IRR) of risk intervals compared with control intervals.ResultsIn total, 13 261 521 patients who received the fluVc were extracted from the National Health Insurance Research Database in Taiwan from January 1, 2010, to December 31, 2017. Of those, 7 581 205 patients older than 65 years old met the inclusion criteria. The number of patients with BP diagnosed within 6 months following fluVc enrolled for risk analysis was 4367 (mean [SD] age, 74.19 [5.97] years; 2349 [53.79%] female patients). The incidence rate of BP among all observed fluVc older adults was 57.87 per 100 000 person-years. The IRRs for BP on days 1 through 7, days 8 through 14, and days 15 through 30 were 4.18 (95% CI, 3.82-4.59), 2.73 (95% CI, 2.45-3.05), and 1.67 (95% CI, 1.52-1.84), respectively. However, there was no increase during days 31 through 60 (IRR, 1.06; 95% CI, 0.97-1.16). The postvaccination risk of BP was consistent across all subgroups stratified by sex, age group, and baseline conditions.Conclusions and RelevanceThe present self-controlled case series indicated that the risk of BP in individuals older than 65 years increased within the first month, especially within the first week, following fluVc. But overall, the adverse event rate of BP was low, and considering the morbidity and mortality of influenza infection, the benefits of fluVc still outweigh the risks.

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“…The entity capsular warning syndrome (CWS) was first coined by Donnan et al in 1993 to describe the phenomenon of at least 3 crescendo transient ischaemic attacks (TIAs) restricted to the region of the internal capsule, usually causing symptoms affecting the face, arm, and leg within a 24-h period [ 1 ]. Later studies used broader timeframes to define CWS up to 7 days, but it remains rare and constitutes only 1.5 to 4.5% of TIAs [ 2 ]. CWS has been associated with the highest stroke risk of up to 30% out of all TIA types [ 3 ].…”

Section: Introductionmentioning

confidence: 99%

Capsular warning syndrome—a case of atrial fibrillation and corona radiata infarct

Tan,

Heng

2023

Int J Emerg Med

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Background Capsular warning syndrome (CWS) is a rare clinical syndrome characterised by recurrent and transient episodes of focal neurological deficits with high risk of infarction. The exact physiological mechanism of CWS remains unclear but is most commonly believed to be a result of haemodynamic insufficiency in diseased, small penetrating vessels. There are no defined treatment guidelines or established effective therapy. Case presentation We describe the case of a 65-year-old man who presented to the emergency department with recurrent episodes of dysarthria coupled with right facial droop and right-sided weakness. Symptoms recurred a total of ten times within a span of 3 h. He had new onset atrial fibrillation. An initial cerebral angiogram showed mild intracranial atherosclerotic disease with no proximal large vessel occlusion or acute infarct. Magnetic resonance imaging 1 h later demonstrated an infarct in the left corona radiata. Conclusions This case illustrates an uncommon etiology of CWS. We will also discuss the lack of consensus in treatment options for CWS to mitigate a complete stroke.

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Stroke warning syndrome

Cited by 6 publications

References 56 publications

Case report: Concurrent low-volume subdural hematoma and ipsilateral ischemic stroke presenting as capsular warning syndrome: a complex case with anticoagulation dilemma and dual pathology

Case report: Concurrent low-volume subdural hematoma and ipsilateral ischemic stroke presenting as capsular warning syndrome: a complex case with anticoagulation dilemma and dual pathology

Association of Influenza Vaccination With Risk of Bell Palsy Among Older Adults in Taiwan

Capsular warning syndrome—a case of atrial fibrillation and corona radiata infarct

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