Abstract
A 75-year-old previously well right-handed woman presented as a code stroke within 2 hours of sudden onset global aphasia. Examination revealed GCS 10 (E4, V1, M5), transient rightward gaze deviation, otherwise normal tracking eye movements, spontaneous movement of all limbs, and non-brisk reflexes with flexor plantar responses. CT stroke imaging revealed no established infarction or large vessel occlusion. CT perfusion (CTP) showed marked global hyperperfusion of bilateral cerebral hemispheres and subcortical structures. Non-convulsive status epilepticus (NCSE) was suspected and the patient was commenced on anti-epileptic and empirical anti-microbial therapy. Electroencephalography revealed left frontotemporal rhythmic delta activity with frequent ictal spikes consistent with focal NCSE. Initial CSF analysis was acellular with mildly raised protein 0.56g/L. Infectious, autoimmune, limbic, paraneoplastic and metabolic panels were negative in serum and CSF. Brain magnetic resonance imaging revealed T2 hyperintensity of the left hippocampus in keeping with ictal/post-ictal change without underlying structural abnormality. MR perfusion confirmed diffuse increase in regional cerebral blood volume of bilateral cortical and subcortical grey matter. The patient‘s language returned after 72 hours of seizure management in the intensive care unit. Progress CTP revealed resolution of perfusion abnormalities. Progress cerebrospinal analysis revealed mild monocytic pleiocytosis (8x10^6/L) with positive Herpes Simplex Virus 2 PCR. The patient completed 14 days of IV aciclovir. On discharge, the patient had new mild cognitive deficits but no further seizures. This case highlights the utility of CTP in the identification of stroke mimics such as NCSE, leading to prompt treatment and avoiding unnecessary and potentially harmful treatments.
