Guerrero et al. International Journal of Emergency Medicine 2012, 5:4 http://www.intjem.com/content/5/1/4 C A S E R E P O R T Open Access The role of perfusion CT in identifying stroke mimics in the emergency room: a case of status epilepticus presenting with perfusion CT alterations Waldo R Guerrero*, Haitham Dababneh and Stephan Eisenschenk 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. Background The differentiation between stroke and seizure can be a clinically arduous task for both emergency medicine physicians and neurologists [1,2]. Patients with diseases that mimic stroke account for one-fifth of patients with brain attacks [1]. Imaging may therefore be critical in making a diagnosis in the acute setting. Seizure is one condition that can mimic a stroke. Commonly, patients with Todd’s paralysis or those with nonconvulsive status epilepticus can be clinically indistinct from those with acute stroke. Further complicating the clinical scenario, seizure may also be a presenting sign of stroke [3]. Recently the time frame for standard treatment of acute stroke with IV tissue plasminogen activator was expanded from 3 h to 4.5 h from ictus onset [4]. Although this extension of time is supported by the American Heart Association, it is not FDA approved and comes with a different set of relative contraindica- tions. Intravenous thrombolytics are not without the risk of complications, including intracranial hemorrhage [5]. Non-contrast CT (NCCT) of the head is the current gold standard in excluding intracranial hemorrhage prior to administration of intravenous thrombolysis. However, NCCT has a limited role in differentiating those patients with stroke from those with seizure. * Correspondence: waldo.guerrero@neurology.ufl.edu Department of Neurology, College of Medicine, University of Florida, 1601 Archer Road Gainesville, 32610-0236 FL, USA Although current guidelines advocate only NCCT as the imaging modality of choice in the initial evaluation of acute stroke, this case illustrates the importance of CT perfusion studies in the radiographic evaluation of brain attack patients in order to avoid misdiagnosis and inad- vertent treatment of non-stroke patients with thrombo- lytic therapy. Furthermore, whereas hypoperfusion related to strokes has been widely investigated by CT- perfusion imaging [6,7], this case demonstrates the hyperperfusion state often seen on perfusion CT in emergency room patients with epilepsy. We describe an interesting case of a patient presenting to the Shands Hospital at the University of Florida emergency room with a homonymous hemianopsia and alterations on perfusion CT related to hyperglycemia-induced occipital status epilepticus. Case presentation A 72-year-old man with a past medical history signifi- cant for diabetes mellitus type 2 presented to the Shands Hospital at the University of Florida emergency room with sudden onset of visual changes. The patient had noted that he would miss objects when reaching for them at home. He also noted black and red spots and prisms in his vision. There was no previous history of seizures. His risk factors for stroke included his age, dia- betes type 2, as well as tobacco use. The NIH Stroke Scale score on presentation was 2 with a complete left © 2012 Guerrero et al; licensee Springer. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.