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Clinical Pearl: ‘Positive’ Symptoms May Be Acute Stroke: Emergency Medicine News


positive symptoms, acute stroke


It is commonly accepted that TIAs and strokes generally exhibit “negative” symptoms while imitators (eg, migraine, seizures) generally exhibit “positive” symptoms. Doctors should be aware, however, that “positive” symptoms such as certain abnormal movements can be an acute stroke.

Sudden hyperkinetic movements are a presentation of acute ischemic stroke, usually secondary to basal ganglia and thalamic infarction, but can result from damage to the cortex. Sudden onset of hemichorea or hemiballism should be considered an acute stroke until proven otherwise.

Hemichorea is characterized by rapid and unpredictable contractions primarily affecting the distal limbs, which are involuntary and non-repetitive or rhythmic. Hemiballism refers to unilateral, proximal, large-amplitude involuntary movements of a throwing or kicking character. Hemichorea and hemiballism often coexist, and stroke is the most common etiology of the acute onset of hemichorea-hemiballism. (Emerg Med clinical practice cases. 2021; 5[3]: 350;; J Stroke Cerebrovasc Dis. 2020; 29[10]: 105150;

TIA limb shaking presents as a paroxysmal involuntary hyperkinetic movement affecting the contralateral arm, hand, or leg and indicates severe carotid-occlusive disease. Symptoms often occur after maneuvers that decrease cerebral blood flow (eg, orthostasis or hyperextension of the neck). This form of TIA is often misdiagnosed as focal motor seizures. (priest. 2020; 12[5]: e8157;; Neurol case representative. 2020; 12[S1]: 84;

Bilingual aphasia is also an atypical presentation of stroke in the multilingual patient where isolated aphasia occurs in one language while the other remains unchanged. (Emerg Med clinical practice cases. 2021; 5[3]: 325; Bilingual aphasia is considered an indication of fibrinolysis given the impact that a pure aphasic stroke has on quality of life.

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