Missing deadly etiologies in stroke triage: What else could this be?

摘要

We thank Dr. Doig and colleagues for their excellent review of thrombotic microangiopathies, including thrombotic thrombocytopenic purpura (TTP), drawing on insights from an unfortunate case of a young man who presented with acute neurologic symptoms that initially resulted in a telephone consult with the on-call stroke neurologist. Increasingly, TTP is being recognized as an important, uncommon cause of ischemic stroke in young adults; it is worth noting that none of the patients in a recent series of 17 cases had the classical pentad of signs suggestive of TTP. As in the case reported by Dr. Doig and colleagues, patients with TTP often have unremarkable computed tomography (CT) scans of the head and CT angiography (CTA) of the head and neck. It is magnetic resonance imaging — not reported in this case and often not feasible in a peripheral hospital or overnight emergency department setting — that reveals multiple infarcts on diffusion-weighted imaging. These realities make it very easy for a triaging stroke physician to miss TTP despite it being a potentially deadly cause of neurologic symptoms.