CT perfusion: stroke, seizure or both?

An 88-year-old male with a history of hypertension, ischaemic heart disease and Bell’s palsy presented with symptoms and signs of an acute ischaemic stroke. National Institutes of Health Stroke Scale (NIHSS) was 19 at presentation, indicative of potential large vessel occlusion. The initial CT scan revealed evidence of small vessel disease and arterial calcification. As there were no contraindications, he received thrombolytic treatment. CT angiography and CT perfusion imaging were performed in preparation for possible thrombectomy. There was no evidence of a large vessel thrombus, and changes on CT perfusion were suggestive of seizure activity, with relative hyperperfusion on the cerebral hemisphere of interest. Post thrombolysis, his NIHSS was 5. An MR scan revealed evidence of bilateral thalamic infarcts. After a period of rehabilitation, he was discharged home and independently mobile but with cognitive impairment.Acute stroke care increasingly uses multimodal imaging to confirm the clinical diagnosis and help optimise initial emergency management. Such imaging is useful in determining whether the presentation is a vascular event or stroke mimic. Moreover, seizures complicate and mimic acute strokes, which can lead to therapeutic uncertainty. This case highlights the increasingly sophisticated investigation of patients presenting with suspected acute stroke, with the attendant need for accurate interpretation by experienced clinicians.

Two Focal Seizure in a Patient Caused by Different Mechanism

Poststroke epilepsy is the most common cause of epilepsy in adult. Acute symptomatic seizure is a provoked seizure usually caused by systemic metabolic disorders. If stroke patient has a seizure, it is very important to discriminate whether it is a poststroke epilepsy or provoked seizure. The reason is that there are differences in the approach to treatment and the continuation of antiepileptic drugs. We report a stroke mimic patient who had two different mechanisms of focal seizures.

Intravenous Thrombolysis for a Stroke Mimic Patient

The authors present the case of a young woman on phentermine and herbal supplements who presented as an acute stroke alert with right-sided facial droop and numbness. She was treated acutely with intravenous tissue plasminogen activator (tPA). However, the workup did not reveal any evidence of cerebrovascular disease or cerebral infarct. The authors discuss plausible stroke mimics and the safety of administering tPA to such patients.

Spontaneous Spinal Epidural Hematoma Mimicking Stroke and Its Outcome post Intravenous Thrombolysis

<b><i>Background and Purpose:</i></b> Spontaneous spinal epidural hematoma (SSEH) is a rare neurological emergency. Its presentation, depending on location of hematoma, could mimic stroke. While intravenous thrombolysis (IVT) is recommended to commence as early as possible in case of acute ischemic stroke, it is likely that it could be given to SSEH patients. We aimed to examine the prevalence, outcome, and prognosis of such patients. <b><i>Methods:</i></b> We have retrospectively screened all patients given IVT from January 2008 to March 2021 admitted to United Christian Hospital, a tertiary hospital in Hong Kong. We reviewed the final diagnosis of all patients and included cases diagnosed with SSEH. Their clinical and radiological features, treatment, and outcome were analyzed. We further performed a literature review to search for all cases with SSEH given IVT and review their clinical features and outcome. <b><i>Results:</i></b> Out of a total of 940 patients over the 12-year span, 2 patients were diagnosed with SSEH, accounting for 0.21% of cases. From our literature search, to date, there are only 10 cases that had been reported from 5 case reports where IVT was given to SSEH patients. Of the 12 cases, all presented with hemiparesis and 9 with pain. Of those with neck pain, 3 with initial computed tomography angiogram done showed SSEH which was missed initially. Eight were treated surgically and 4 conservatively. All recovered with no major disability. <b><i>Conclusions:</i></b> Though a rare disease, awareness toward SSEH presenting as stroke mimic should be raised.