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The Role of perfusion CT in identifying stroke mimics in the emergency room: a case of status epilepticus presenting wit...
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Permanent Link: http://ufdc.ufl.edu/AA00010129/00001
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Title: The Role of perfusion CT in identifying stroke mimics in the emergency room: a case of status epilepticus presenting with perfusion CT alterations
Series Title: International Journal of Emergency Medicine
Physical Description: Archival
Language: English
Creator: Guerrero, Waldo R.
Dababneh, Haitham
Eisenschenk, Stephan
Publisher: BioMed Central
Publication Date: 2012
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Abstract: Emergency medicine physicians are often faced with the challenging task of differentiating true acute ischemic strokes from stroke mimics. We present a case that was initially diagnosed as acute stroke. However, perfusion CT and EEG eventually led to the final diagnosis of status epilepticus. This case further asserts the role of CT perfusion in the evaluation of patients with stroke mimics in the emergency room setting.
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Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution.
Resource Identifier: doi - 10.1186/1865-1380-5-4
System ID: AA00010129:00001

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CASEREPORTOpenAccess TheroleofperfusionCTinidentifyingstroke mimicsintheemergencyroom:acaseofstatus epilepticuspresentingwithperfusionCT alterations WaldoRGuerrero ,HaithamDababnehandStephanEisenschenk Abstract Emergencymedicinephysiciansareoftenfacedwiththechallengingtaskofdifferentiatingtrueacuteischemic strokesfromstrokemimics.Wepresentacasethatwasinitiallydiagnosedasacutestroke.However,perfusionCT andEEGeventuallyledtothefinaldiagnosisofstatusepilepticus.ThiscasefurtherassertstheroleofCTperfusion intheevaluationofpatientswithstrokemimicsintheemergencyroomsetting. Background Thedifferentiationbetweenstrokeandseizurecanbea clinicallyarduoustaskforbothemergencymedicine physiciansandneurologists[ 1,2].Patientswithdiseases thatmimicstrokeaccountforone-fifthofpatientswith brainattacks[1].Imagingmaythereforebecriticalin makingadiagnosisintheacutesetting.Seizureisone conditionthatcanmimicastroke.Commonly,patients withTodd ’ sparalysisorthosewithnonconvulsivestatus epilepticuscanbeclinicallyindistinctfromthosewith acutestroke.Furthercomplicatingtheclinicalscenario, seizuremayalsobeapresentingsignofstroke[3]. Recentlythetimeframeforstandardtreatmentofacute strokewithIVtissueplasminogenactivatorwas expandedfrom3hto4.5hfromictusonset[4]. Althoughthisextensionoftimeissupportedbythe AmericanHeartAssociation,itisnotFDAapproved andcomeswithadifferentsetofrelativecontraindications.Intravenousthrombolyticsarenotwithoutthe riskofcomplications,includingintracranialhemorrhage [5].Non-contrastCT(NCCT)oftheheadisthecurrent goldstandardinexcludingintracranialhemorrhage priortoadministrationofi ntravenousthrombolysis. However,NCCThasalimitedroleindifferentiating thosepatientswithstrokefromthosewithseizure. AlthoughcurrentguidelinesadvocateonlyNCCTasthe imagingmodalityofchoiceintheinitialevaluationof acutestroke,thiscaseillustratestheimportanceofCT perfusionstudiesintheradiographicevaluationofbrain attackpatientsinordertoavoidmisdiagnosisandinadvertenttreatmentofnon-strokepatientswiththrombolytictherapy.Furthermore,whereashypoperfusion relatedtostrokeshasbeenwidelyinvestigatedbyCTperfusionimaging[6,7],thiscasedemonstratesthe hyperperfusionstateoftenseenonperfusionCTin emergencyroompatientswithepilepsy.Wedescribean interestingcaseofapatientpresentingtotheShands HospitalattheUniversityofFloridaemergencyroom withahomonymoushemianopsiaandalterationson perfusionCTrelatedtohyperglycemia-inducedoccipital statusepilepticus. Casepresentation A72-year-oldmanwithapastmedicalhistorysignificantfordiabetesmellitustype2presentedtothe ShandsHospitalattheUniversityofFloridaemergency roomwithsuddenonsetofvisualchanges.Thepatient hadnotedthathewouldmissobjectswhenreachingfor themathome.Healsonotedblackandredspotsand prismsinhisvision.Therewasnoprevioushistoryof seizures.Hisriskfactorsforstrokeincludedhisage,diabetestype2,aswellastobaccouse.TheNIHStroke Scalescoreonpresentationwas2withacompleteleft *Correspondence:waldo.guerrero@neurology.ufl.edu DepartmentofNeurology,CollegeofMedicine,UniversityofFlorida,1601 ArcherRoadGainesville,32610-0236FL,USA Guerrero etal InternationalJournalofEmergencyMedicine 2012, 5 :4 http://www.intjem.com/content/5/1/4 2012Guerreroetal;licenseeSpringer.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommons AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductionin anymedium,providedtheoriginalworkisproperlycited.

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homonymoushemianopsia.Hepresentedwithin3hof symptomonset,andperfusionCTwasobtainedperthe strokeprotocolatourinstitution.Non-contrastCTdid notrevealanyearlysignsofstrokeorhemorrhage.The CTangiogramwasunremarkable.PerfusionCTdemonstratedanareaofshortenedmeantransittime(MTT), increasedcerebralbloodvolume(CBV),andincreased cerebralbloodflow(CBF)intherightoccipitalterritory (Figure1).Giventhepatient ’ slefthomonymoushemianopsia,thefindingsonperfusionCTwereinterpretedas ahyperperfusionphenomenon.Thedifferential diagnosisincludedepileptiformactivityaswellasother pathologiesnotlimitedtogliomaandmiseryperfusion syndrome.Thus,anEEGwasobtained,anditconfirmed nonconvulsiveseizureactivityfromtherightparietooccipitalquadrant.Thispatientwaseligibleforintravenousthrombolysisgiventhe neurologicalfindingsand NIHSSof2;however,theconstellationoftheabove findingsledtoourclinicaldecisionnottoadminister thrombolyticsinthesettingofaseizurediagnosis.The patientwasloadedwithAtivan,Fosphenytoin,and Depakoteinordertostoptheseizures.Oncethe Figure1 CTperfusionstudydemonstrating(a)shortenedmeantransittimeintherightoccipitalterritory( arrow ) .Correspondingarea ofincreasedcerebralbloodvolume( b )andincreasedcerebralbloodflow( c ).FLAIRMRIbrain( d )withoutevidenceofinfarct. Guerrero etal InternationalJournalofEmergencyMedicine 2012, 5 :4 http://www.intjem.com/content/5/1/4 Page2of4

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seizureswerecontrolled,thepatient ’ sneurologicalexam normalized.Follow-upFLAIRMRIbrainimagingdid notrevealevidenceofstroke(Figure1).DiscussionStrokemimicsaccountfor5-30%of “ brainattacks. ” Of thosepatientsreceivingthrombolytictherapyintheEuropeanCooperativeAcuteStrokeStudyII(ECASSII),17% wereultimatelyshowntonothavehadstrokes[8].Commonconditionssuchasmigraine,epilepsywithandwithoutTodd ’ sparalysis,hypoglycemia,andsinusthrombosis canoftenmimicstroke[9,10].Unfortunately,NCCTis notasensitiveradiographictoolindetectingstroke becauseparenchymalchangesdonotusuallyappearearly inthecourseofacutestroke[1,11].MRIwouldoffergood accuracyandsensitivityinsuchcases[12].However,itis oftennotutilizedbecauseofitsdecreasedavailabilityin contrasttotheshortacquisitiontimeandwideavailability forNCCTintheemergencyroomsetting. TherearedatasupportingtheuseofCTperfusionin acutestrokemanagement[11].RelativeMTTandabsoluteCBVareCTperfusionparametersthathelpdefine areasofinfarctfromareasofpenumbra[6].Itsusehas alsobeeninvestigatedforthediagnosisofseizures [13,14].Haufetal.demonstratedthatperfusionCTisa usefultoolinaccelerating thediagnosisofnonconvulsivestatusepilepticuswithasensitivityof78%[15].In thiscase,corticalhyperperfusionwasobservedas reflectedbyadecreaseinmeantransienttime(MTT) andaconcomitantincreaseincerebralbloodvolume (CBV)andflow(CBF)(Figure1).Thisiscompatible withpreviousdatademonstratingincreasedCBVand CBFvaluesintheseizureonsetzoneaswellasinthe regionswithictalspread[13].Thishyperperfusionstate duringtheictalstatehasalsobeenshownwithSPECT andf-MRIinpatientswithfocalepilepsy[16,17]. CTperfusionhastheadvantagesofroutineavailability,shortacquisitiontime,andquantitativeresults.This casefurthersupportstheroleofCTperfusioninthe emergencyroomsettingwhenassessingstrokepatients forthrombolytics.Althoughpatientswithstrokemimics infrequentlyreceivethrom bolyticsandtheirtreatment generallydoesnotleadtoharmfulcomplications[18], CTperfusionmaysparepatientswithstatusepilepticus fromthemisguidedtreatmentofintravenousthrombolysis.PCTmayalsoqualifyasacomplementarydiagnostictoolinpatientspresentingtotheemergencyroom withalteredmentalstatusinwhichstrokeisalsoaconsiderationforetiology.ConclusionsInsummary,perfusionCTcanserveanimportantrole indifferentiatingacutestrokefromanunusualpresentationofstatusepilepticusintheemergencyroomsetting.ConsentWritteninformedconsentwasobtainedfromthepatient forpublicationofthiscasereportandanyaccompanyingimages.Acopyofthewrittenconsentisavailable forreviewbytheEditor-in-Chiefofthisjournal.Abbreviations NCCT:non-contrastCThead,MTT:meantransittime.CBV:cerebralblood volume,CBF:cerebralbloodflow,SPECT:single-photonemissioncomputed tomography,f-MRI:functionalmagneticresonanceimaging. Acknowledgements PublicationofthisarticlewasfundedinpartbytheUniversityofFlorida Open-AccessPublishingFund. Authors ’ contributions WGdraftedthemanuscriptandcollectedtheimagesandfigureutilizedin thismanuscript.HDeditedthemanuscriptandassistedinCTperfusion imageinterpretation.SEeditedthemanuscriptaswellassupervised.All authorsreadandapprovedthefinalmanuscript. Authors ’ information WGandHDarebothfourthyearNeurologyresidentsattheUniversityof Florida.SEisAssociateProfessorofNeurology,ClinicalDirector,Adult NeurologyComprehensiveEpilepsyProgram,andMedicalDirector,UF& ShandsEpilepsyMonitoringUnit. Competinginterests Theauthorsdeclarethattheyhavenocompetinginterests. Received:7November2011Accepted:20January2012 Published:20January2012 References1.DavisDP,RobertsonT,ImbesiSG: Diffusion-weightedmagneticresonance imagingversuscomputedtomographyinthediagnosisofacute ischemicstroke. 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