stroke

Seizure is clinical manifestation of sudden disruption of the normal electrical activity of cortical neurons. The brain electrical activity is periodically disturbed, alteration in neural cell integrity, increase in firing impulses and spread to adjacent normal neurons result in temporary brain dysfunction with alterations in consciousness, behavior or motor function. It may be triggered by illness, infection, stress, stroke, brain tumor, or the underlying cause may not completely understand. Status epilepticus (SE) is a medical emergency and requires prompt diagnosis and treatment. Treatment includes general support measures, drugs to suppress epileptic activity and relieving the underlying condition. Refractory SE requires admission to an intensive care unit (ICU) to allow adequate monitoring and support of respiratory, metabolic and hemodynamic functions and cerebral electrical activity. For SE treatment, benzodiazepines are the first line antiepileptic agents, and if benzodiazepines fail to control seizures, Phenytoin is usually indicated; Phenobarbital or Valproate may also be considered. For refractory SE, Propofol and Thiopental represent first line agents after careful assessment of potential risks. In refractory SE, general anesthesia may be required. There is currently no unique consensus for definite treatment option of RSE. In this review, the management protocol of seizure, assessment, monitoring, and different alternative therapy would be discussed.

We report a case of 79-year-old man who presented to our emergency department (ED) for lipothymia. The patient developed significant bradycardia with hypotension. His EKG objectified a slow atrial fibrillation .the patient rapidly installed a coma. A non-contrast CT brain scan showed a bilateral vertebrobasilar ischemic stroke. 

Introduction: Hypertensive crisis (HC) is recognized consequence of inadequate blood pressure (BP) control. A hypertensive crisis is further divided into hypertensive emergency (HT-E) and hypertensive urgency (HT-U). Method: Using a cross-sectional hospital-based study design, patients who had been diagnosed as having HC between January and October 2017 were consecutively recruited in the study. The criteria proposed by the Seventh Joint National Committee were used for the definition of HC. Result: A total of 81 (.81%) patients newly diagnosed as having HC were enrolled in the study. Of these patients, 50 (61.7 %) patients met criteria for HT-E, while 31 (38.3%) patients had HT-U. Renal impairment (16%), stroke (30.8%), acute coronary syndrome (13.6%) and heart failure (22.2%) were predominant complications associated with HT-E. Out of 81 study subjects, 13 (16%) patients died. Although there was no significant difference in residence, history of smoking, Diabetes mellitus and history of alcohol consumption between groups, old age (P=.o22), male gender(.046), history of hypertension(.007), history of non-governmental employee(.003), poor compliance (p=.002) and high case fatality rate (p=.041) were significantly associated with hypertensive emergency (HT-E). Conclusion: This study showed that HT-E has high case fatality rate among patients admitted with hypertensive crisis at kassala teaching Hospital. Therefore early detection of hypertension and appropriate management are the main stay for reducing morbidity and mortality among patients with hypertensive crisis.

Stroke following coronary interventions is a devastating and most dreaded complication with signiβicant morbidity and mortality. Various factors have been ascribed for this complication including the technical errors [1]. A small percentage of strokes are iatrogenic, including those associated with invasive cardiac procedures. According to the literature, it is a rare complication of left heart catheterization [2]. Percutaneous coronary intervention is increasingly used to treat patients with diffuse atherosclerosis, acute coronary syndromes and even high-risk patients such as low ejection fraction [1]. The authors describe a patient who underwent percutaneous coronary intervention in the context of inferior infarction, which was complicated by ischemic stroke during cardic catheterization.

Background: In line with the so-called “embodiment concept”, human bodily experience is characterized by the immediate feeling that our body is localized in a certain position in space and that the self is localized within these body limits. Aim: To verify in a cohort of patients affected by unilateral spatial neglect (NSU) secondary to cerebrovascular damage the possible correlation between a comprehensive neuromotor/neuropsychological rehabilitative treatment and the modification of body representation. Setting: A rehabilitation institute for the treatment of neurological gait disorders and neuropsychological failures. Methods: 12 patients (7 males, 5 females; mean age 60 ± 2yy) affected by NSU secondary to cerebral stroke and recovered in the Neurological Rehabilitation Section of the Clinical Institute Città di Brescia were recruited for the aim of this study. In accordance with our inclusion criteria we recruited 4 patients affected by ischemic stroke and 8 patients affected by haemorragic stroke; 9 patients of our study group arrived from a coma state period. Recruited patients underwent at time T0 (hospitalization day) to a functional impairment evaluation (Motricity Index = MI; Trunk Control Test = TCT; Functional Ambulation Category = FAC) and to a neuropsychological evaluation (Behavioural Inattention Test = BIT; Representional drawing; Personal Neglect evaluation scale); each evaluation was repeated in the same way at time T1 (intertime between 2 and 4 months after hospitalization) and time T2 (inter time between 5 and 6 months after hospitalization). At time T0 each patient began an individualized integrated (motor and neuropsychological) rehabilitative treatment course. Results: In all patients recruited a statistical significant modification was observed for the MI LL left, the TCT and the FAC; no significant statistical modification was observed for the MI UL left, the MI UL and the MI LL right. The t-test showed a significant statistical modification of the personal neglect evaluation scale while no significant statistical modification was defined for the spontaneous human figure drawing test proceeding from time T0 to time T1. The spontaneous drawing of the human figure showed an individual different trend and modification in all patients recruited. A correlation analysis was made comparing the mean value of all motor scales (G1) with the mean value of all neuropsychological scales (G2) and no statistical significant correlation was observed between G1 (T0) and G1 (T1), G1 (T0) and G2 (T0), G1 (T0) and G2 (T1), G2 (T0) and G1 (T1), G2 (T0) and G2 (T1), G1 (T1) and G2 (T1). A second correlation analysis was made comparing all single motor scales with the neuropsychological scales, for the group made by 12 patients and the group made by 5 patients. For the group made by 12 patients, we observed the subsequently significant correlations: MI UL left (T0) correlates with MI LL left (T0); MI LL left (T0) correlates with MI LL left (T1); MI UL left (T1) correlates with MI LL left (T1); MI LL left (T1) correlates with FAC (T1); TCT (T1) correlates with FAC (T1). For the group made by 5 patients, we observed the subsequently significant correlation: TCT (T2) correlates with FAC (T2). In the group made by 12 patients, the mean amelioration of the time related normalized (T0-T1) motor scales is equal to 49% while to 63% was observed for the neuropsychological scales. The mean amelioration of the neuropsychological scale proceeding from time T0 to T1 is equal to 26% with an increase equal to 57% proceeding from time T1 to T2. The neurocognitive amelioration can be observed especially between the 5th and 6th month from the ischemic cerebral damage with a mean increase from 26% to 57%. Conclusions: It would certainly make sense to treat patients with NSU from the neuropsychological point of view in the long term and from the neuro-motor point of view in the first 3-4 months after stroke; in all this, we cannot exclude that an improvement of the visuo-spatial exploration, emphasized by the neuropsychological treatment, can positively influence also patient’s motor outcome.

The normal levels of thyroid hormones (THs; thyroxine, T4 & 3,5,3′-triiodo-L-thyronine, T3) are necessary for the normal development [1-48], particularly the fetal and neonatal cardiac growth and development [49]. The actions of THs are facilitated genomically by thyroid receptors (TRs, α and β) and non-genomically at the plasma membrane, in the cytoplasm and in cellular organelles [4,49-55], by stimulation of Na+, K+, Ca2+ and glucose transport, activation of protein kinase C (PKC), protein kinase A (PKA) and mitogen activated and protein kinase (ERK/MAPK) [4]. In addition, the transport of T4 and T3 in and out of cells is controlled by several classes of transmembrane TH-transporters (THTs) [56], including members of the organic anion transporter family (OATP), L-type amino acid transporters (LATs), Na+/Taurocholate cotransporting polypeptide (NTCP), and monocarboxylate transporters (MCTs) [4,49,57,58]. Adding additional complexity, the metabolism of T4 and T3 is regulated by 3 selenoenzyme iodothyronine deiodinases (Ds: D1, D2 and D3) [59-61]. On the other hand, the congenital hypothyroidism can cause the following [49,62-64], (1) congenital heart diseases; (2) diastolic hypertension; (3) reduced cardiac output, stroke volume and a narrow pulse pressure; (4) dilatation and overt heart failure; (5) elevation in the systemic vascular resistance [65-68]. Similarly, the chronic hyperthyroidism can cause the following [49,64]: (1) cardiac hypertrophy; (2) increase in the cardiomyocyte (CM) length rather than width; (3) noticeable diminution in systemic vascular resistance; (4) elevation in the cardiac contractility; (5) systolic hypertension; (6) increase in the cardiac output, venous volume return, blood volume and pulse pressure; and (7) reduction in the systemic vascular resistance [49,69]. T3-therapy can induce DNA synthesis and cardiomyocyte proliferation, and improve the cardiac contractility; though, this action is as still unidentified [49,70-74].

Objective: We evaluated the 30-day outcomes of early (≤ 14 days) or delayed (15 days to three months) carotid revascularization (CR) performed in patients who presented acute brain infarction secondary to internal carotid artery (ICA) stenosis. Methods: We included all patients with a recent cerebral infarction from July 2010 to June 2014 who underwent CR in our center within three months after the onset of symptoms for ICA stenosis. Data were retrospectively collected. Two groups were identifi ed: Group A included patients who underwent early CR within the first fourteen days after symptom onset, and Group B, patients who underwent delayed CR, from the fifteenth day up to the third month after symptom onset. Death, stroke and major adverse cardiac events (MACE) were analyzed. Results: Seventy-one patients underwent CR (73.2% men, with a median age of 71). Nineteen patients underwent early CR and 52 underwent delayed CR. The mean interval from initial examination to surgery was 9.5 days (range, 3-14 days) in Group A and 42 days (range, 15-92 days) in Group B. No complication occurred in Group A within the 30 postoperative days. In Group B, no MACE or death was observed and two patients presented with post-operative stroke (3.8%). Conclusion: This retrospective study confi rmed the satisfactory outcomes of early CR after acute brain infarct. Accurate clinical and radiological selection of patients prevents early neurological complications.

Stroke and neurodegenerative diseases including Alzheimer’s disease (AD) are responsible for a major proportion of mortalities in the elderly. We have previously investigated novel mechanism-based therapies of AEURA in cell culture models against viral infection and in glutamate excitotoxity. In our new studies, we propose that the homeopathic formula AEURA could serve as a potential therapeutic agent for stroke & for AD. In examining AEURA treatment of PC12 cells exposed to glutamate excitotoxicity, hypoxia /re-oxygenation injury and A-Beta toxicity. We demonstrated an increased survival rate in AEURA treated cells by comparison to control cells. In examining the therapeutic potential of AEURA in PC12 cells this homeopathic agent was found to be neuroprotective against either glutamate induced toxicity, hypoxia /re-oxygenation stress or cell stress resulting from viral infection (with either HSV-1 or rhinovirus). Our ongoing studies involve examining the neuroprotective potential AEURA in vivo using rodent models of stroke & AD.

Here we reported an interesting case of an 84-year-old woman with acute onset of paresis of left arm and paresthesia of left face and arm. The symptoms resolved within two hours. She also had a similar prior episode two weeks ago with only left arm paresthesia. Her MRI revealed different stages of lacunar ischemic lesions. Interestingly, the SWAN sequences showed lateralized rather than global multiple microhemorrhages over the right MCA and PCA territory, and the sulcal hyperintensity on FLAIR was also seen with no associated susceptibility effect and minimal enhancement, indicating probable cerebral amyloid angiopathy (CAA) based on Boston Criteria. It has been acknowledged that the CAA could manifest with certain localization preference. Cerebral microinfarct and white matter disease in CAA have been more often observed in the posterior circulation territory, however the restricted lateralization reported in our case has not been seen. Since CAA is often diagnosed when the characteristic MRI findings are picked up incidentally, recognizing this as a potential “TIA mimic” will be important for guiding treatment due to its higher risk of bleeding. In summary, this case highlights that the CAA could present as restricted lateralized lesions and occur as transient neurologic deficits, which to our knowledge has not be reported before. Recognition of it as a potential manifestation of CAA will be valuable in the clinical diagnosis process.

As per report of WHO [1] (World Health Organization), air pollution (ambient/outdoor and household/indoor air pollution) kills an estimated seven million people worldwide every year largely as a result of increased mortality from stroke, heart disease, chronic obstructive pulmonary disease, lung cancer and acute respiratory infections. Data of WHO shows that 9 out of 10 people breathe air containing high levels of pollutants. World Health Organization is working with countries to monitor air pollution and improve air quality. From smog hanging over cities to smoke inside the home, air pollution poses a major threat to health and climate. More than 80% of people living in urban areas and around 91% of the world’s population live in places where air quality levels exceed WHO limits, with developing and under-developed countries suffering from the highest exposures, both indoors and outdoors [1]. While outdoor air pollution comes from the motor vehicles, burning of fossil fuels and other industrialization activities, indoor air pollution is the result of tobacco smoke and burning fuel for cooking & heating. Furniture and construction materials also emit such pollutants. Both outdoor and indoor air pollution are harmful to the human health.

Hypertension and blood pressure are closely related, and hypertension is directly related with stroke. There are different type of blood pressures such as basal, diastolic, maximum, mean arterial, systolic, mean central venous. The present report examines the determinants of systolic blood pressure for two different groups of cardiac patients. One group of cardiac patients is those who underwent dobutamine stress echocardiography, and the other group is Worcester heart attack study. Many systolic blood pressure determinants, their effects, and correlations have been focused in the current report.

In this review After Observing biomedical literature (starting from some heart disease) results that some pathological phenomena are deeply involved in some metabolic endocrine condition: Kinetics and gradients in metabolism, catabolism, time related, toxic like effect, electrical cell membrane status, smooth vascular muscle cell hyper-reactivity, platelet iperactivations, central autonomic control after acute stroke, great electrolytes unbalances et other factors as pro-hypertrophic signaling and oxidative stress. Observing actual current therapy in some metabolic endocrine therapy often is used association of drugs (in example in type II diabetes). In Many other pathologies efficacy drug therapy exist, and often only 1 pharmacological molecule resolve the pathological condition. But in many disease even associating 2-3-4 drugs the % of cure not increase (efficacy, effectiveness). It mean that this drugs strategies are not the really best? Or it mean a low active level? Why for this pathological condition this association drugs in currently use not do the right works as really needed? There is the need for new really efficacy drugs strategy that show a profile of efficacy as requested in order to resolve the pathological condition? Or to be added to the actual therapy? The actual pharmacological strategies in some metabolic endocrine disorder is really the best? Or other strategies can be introduced?

Hypertension is one of the most common chronic diseases of human, affecting more than one billion people worldwide. When it becomes chronic, hypertension leaves behind cardiac hypertrophy, heart failure, stroke, and kidney disease, resulting in substantial morbidity and mortality. Treatments that effectively reduce blood pressure can prevent these complications. Abnormalities in the production of urine by the kidneys have been implicated in increased vascular resistance, leading to high blood pressure and increased cardiac mass. By matching urinary excretion of salt and water with dietary intake, balance is usually attained, thereby maintaining a constant extracellular fluid volume and blood pressure. Based on the capacity for the kidney to excrete sodium, this blood pressure-altering mechanism should have sufficient advantage to limit intravascular volume and consequently lower blood pressure in response to a range of stimuli from elevated heart rate to increase peripheral vascular resistance. A major determinant of the level of intra- and extra- renal blood pressure is therefore sodium handling, and it is controlled by complex physiological mechanism by hormones, inflammatory mediators, and the sympathetic nervous system. Homoeostasis and favourable influence sodium balance are a basic mechanism of efficacy for diuretics and dietary sodium restriction in hypertension. Renin Angiotensin System (RAS) inhibitors, vasodilators, and β-blockers work to facilitate pressure-natriuresis. Also, WNK signaling pathways, soluble inflammatory mediators, and pathways regulating extra-renal sodium disposition may be the focus towards elimination of sodium and reducing blood pressure in hypertension.

Today, Mexico has more than 130 million inhabitants; 85 millions of them are adults of 20 or more years old. The population pyramid is still one of base wider and this base corresponds to adults younger than 54 years old. Despite predictions made 20 years ago, about a transformation of the population pyramid shape to a mushroom shape as a consequence of more life expected and adult population growth; this change has not been occurred. Hypertension has become the biggest challenge of noncommunicable chronic diseases to public health in Mexico. Around 30% of adult Mexican population has hypertension; 75% of them have less than 54 years old (in productive age); 40% of them are unaware but only 50% of aware hypertensive population takes drugs and, 50% of them are controlled (< 140/90 mmHg). Cardiovascular risk factors including hypertension, dyslipidemia, obesity, and diabetes often cohabit in the same person and are magnified one to another in terms of common pathophysiological pathways. Atherosclerosis, arrhythmias, stroke and heart failure are common and are the final pathologic end-points and explains why cardiovascular diseases occupy first place in mortality in Mexico and worldwide. The costs of care for these diseases are billionaires and if we do not generate appropriate strategies, their global impact can become a high threat to social development of the country. The life style like nutrition, sports habits of the Mexicans must be emphasized; there is poor education about this crucial topic. This position paper is focused on the principal controversies and strategies to be developed by all, government, society, physicians, nurses, patients and all people related with healthcare of hypertension, in order to confront this huge public health problem in Mexico.

Introduction: Hypertension is a silent pathology in a way that affects all four spheres to be considered as such; magnitude, transcendence vulnerability, and feasibility. The World Health Organization estimates that 45% of deaths from heart disease and 51% of deaths from stroke globally are caused by hypertension. Material and method: A longitudinal, descriptive and quantitative observational study was carried out on the personnel of high-risk public service providers. Results: The total population sampled was 550 people where it was possible to determine the sex where the disease predominates, since 92% of the hypertensive population belong to the male sex, while 8% of the female population. 57% of the total population were classified as normotensive, while 21% were classified as High Normal, Grade I Hypertension, and Grade II Hypertension. Discussion: AHT is the result of a series of interactions between endogenous and exogenous factors in an organism that tries to adapt to the increase of the cardiac output and the peripheral resistance of the blood vessels, which is manifested by the increase in blood pressure figures. Physical activity has been shown to have a lower risk of hypertension compared to sedentary individuals. The daily stress these workers face predisposes them to suffer their manifestations as headache, muscle pain, fatigue, digestive disorders and constant elevations of blood pressure.

Background: NSU is generally caused by right cerebral hemisphere lesions with a preeminent localization on the frontoparietal lobe. Aim: To assess the correlation between the typology and the brain lesion site and the consensual consent modality of body image modification after an integrated rehabilitative and neuropsychological treatment. Setting: A rehabilitation institute for the treatment of neurological gait disorders and neuropsichological failures. methods: Patients recruited were divided according to the brain lesion site into 3 groups (IG = ischemic group = 5 patients; HG = hemorrhagic group = 4 patients; IG + HG = ischemic + hemorrhagic group = 3 patients) based on CT brain performed in the post-acute phase. At time T0, the patients recruited underwent a systematic review of their current neuroradiological profile (location delineation and type of brain injury) compared with a consensual framing of the neuromotor and neuropsychological profile acquired at the time of taking charge in the ward. At time T1 and after the drafting and implementation of the rehabilitation treatment plan foreseen in the study (1 to 4 months after T0), the patients in our sample underwent a re-evaluation of their neuromotor and neuropsychological profile with controls of the same outcome parameters considered at time T0. Results: A parametrically but not statistically significant modification of the results obtained was observed by measuring the MI ULl, MI LLl and TCT scales in the group with hemorrhagic brain injury; the analysis of variance did not show any statistical significance in the relationship between the type of stroke (ischemic, hemorrhagic or both) and the motor impairment passing from time T0 to time T1. The analysis of variance did not reveal a statistically or parametrically significant relationship between the type (ischemic, hemorrhagic and ischemic + hemorrhagic) of cerebral stroke and the variations of the neuropsychological profile. The T-Student test showed statistically significant changes in the importance of the lesion site in defining the degree of motor disability. In particular, we observed, about the presence of frontal lobe lesions, a statistically significant variation passing from the T0 time to the T1 time for the following motor scales in 9 of 12 recruited patients: MI LLl (26.4 vs. 62, with p < 0.05), TCT (43.6 vs. 80.6, with p < 0.01 for equal variance assumed and p < 0.05 for equal variance not assumed), FAC (0.8 vs. 2.3 with p < 0,01 for equal variance assumed and p < 0.05 for equal variance not assumed). Conclusion: We have confirmed the importance of the anatomical-dysfunctional correlation as a key concept from which to start in any neurorehabilitative treatment approach. Our work has highlighted the basic role of the right frontal lobe in the programming and execution of the gesture and its kinesthetic control as regards the left lower limb and the trunk.

Introduction: High proportion of stroke survivors have impaired functional mobility and decrease in overall quality of life (QoL). Transcranial direct current stimulation (tDCS) (non-invasive brain stimulation) and over-ground walking task (OGWT) (functional task-oriented training) have been suggested to improve functional mobility and QoL of stroke survivors. Hence, this study determined the efficacy of tDCS (anodal and cathodal) with OGWT on functional mobility and QoL of stroke survivors. Materials and methods: Seventy eight (78) stroke survivors were randomised into three groups: anodal group (anodal tDCS with OGWT); cathodal group (cathodal tDCS with OGWT) and control group (OGWT only). Participants had two sessions of intervention per week for six weeks. Functional mobility was assessed using 10 meter walk test (10MWT) measuring steps, time and velocity while QoL was measured using Stroke Specific QoL (SSQoL) scale. Significance level was set at p < 0.05. Results: Participants (46 males) were aged 56.78 ± 10.24 years. The groups were matched for functional mobility and QoL at baseline and only work/productivity domain of SSQoL showed statistically significant difference (p = 0.028). Each group showed statistically significant improvement between baseline and post-intervention scores of items in functional mobility (p ≤ 0.001) and total SSQoL (p ≤ 0.001). Anodal group showed better statistically significant improvement in step (p = 0.008), time (p = 0.024), velocity (p = 0.001) and total SSQoL (p = 0.016) among the groups when the mean differences were compared. Conclusion: tDCS with OGWT is efficacious in improving functional mobility and QoL of stroke survivors. Specifically anodal tDCS with OGWT showed better clinical improvement in step, time, velocity and QoL in stroke survivors.

Background: Respiratory muscle strength can be reduced in patients diagnosed with stroke, which reasonably justifies the use of respiratory muscle training in this population. This study determines the comparative efficacy of inspiratory, expiratory, and combined respiratory muscle training on the pulmonary functions and chest expansion in acute stroke survivors. Method: Forty-five acute stroke survivors (15 in each group) completed all protocols of the study. Participants were randomly assigned to any one of three groups. In addition to the conventional exercise therapy, participants received any one of the three respiratory muscle training protocols (inspiratory muscle training, expiratory muscle training or combined respiratory muscle training). Chest expansion was assessed using tape measure and pulmonary function parameters were assessed using a spirometer. Results: Paired t-test analysis showed significant improvements in the chest expansion and the pulmonary function parameters following training in each group. One-way ANOVA showed significant improvements in the pulmonary function parameters across the three groups but not in the chest expansion with p - value = 0.405. Least significant difference (LSD), post-hoc analysis shows that the significant difference for FEV1, FVC and FEV1/FVC lies between inspiratory muscle training group and expiratory muscle training group. Conclusion: When the three training methods were compared, it was found that expiratory muscle training was the most beneficial in improving the pulmonary functions and chest expansion in acute stroke survivors.

Broad-spectrum sunscreens are now widely used worldwide as an adjunct to help prevent sunburn, skin cancers and premature skin aging. In the United States, all persons older than 6 months are recommended to apply sunscreen to all sun-exposed skin from toes to head except eyes and mouth even on cloudy days. Such a recommendation is apparently based on concepts that exposure to sunlight damages the skin, the damage is cumulative and hence any sun exposure should be minimized or prevented. This communication raises several questions suggesting that the above recommendation may need to be reconsidered. For example, numerous previous studies have indicated many potential health benefits from non-burning sun exposure including protection against sunburn, melanoma, colorectal cancer, breast cancer and prostate cancer, increasing vitamin D synthesis, helping sleep, reducing blood pressure, heart attack and stroke. Recent studies suggested that regular lifetime non-burning sun exposure may not result in premature skin aging and the skin aging is mainly caused by the intrinsic factor. Skin aging or whole-body aging has been recently postulated to be mainly attributed to a gradual reduction in cardiac output/index with age and a new anti-aging or age-reversing nutritional theory has been proposed. An apparent lack of long-term cumulative sunray damage was also supported by reported age independence in incidences of sunburn and skin cancers. It is of interest that the current US policy is different from that of World Health Organization and Australia recommending the need of sun protection only when UV Index is 3 or greater. In view of the above, some general guidelines regarding when to best apply sunscreen are proposed.

Pulmonary embolism (PE) is an age-related disorder which is potentially fatal, but frequently misdiagnosed. However, the true prevalence of pulmonary embolism is unknown. Inaccurate estimates of PE prevalence might, in part, be attributable to underrecognition of atypical presentations of this disorder. If true prevalence is unknown, the positive predictive values of both typical and atypical symptoms and signs of PE will be unreliable. The negative predictive value of those parameters will, likewise, be unreliable. The aim of this review is to make clinicians more aware of atypical manifestations of PE, thereby increasing the likelihood of correct diagnosis and, hence, ascertainment of the true prevalence of PE. The range of atypical manifestations was explored by a literature search, using MEDLINE from 1946 to February 2019, and EMBASE, from 1947 to February 2019, and Pubmed, from February 2014 to February 2019, using the search terms atypical, uncommon, unusual, pulmonary embolism, lung embolism, pulmonary thromboembolism. This search revealed atypical presenting features such as non pleuritic retrosternal pain, abdominal pain, atypical breathing patterns, pulmonary oedema, Dressler’s syndrome, atypical radiographic manifestations, atypical electrocardiographic features, manifestations associated with oxygen saturation of 95% or more, coexistence of acute myocardial infarction and pulmonary embolism, coexistence of thoracic aortic dissection and pulmonary embolism, neurological manifestations other than stroke, paradoxical embolism, acute venous thrombosis of atypical location, and pulmonary embolism with normal D-dimer levels.