Guerrero et al. International Journal of Emergency Medicine 2012, 5:4 http://www.intjem.com/content/5/1/4 seizures were controlled, the patient’s neurological exam normalized. Follow-up FLAIR MRI brain imaging did not reveal evidence of stroke (Figure 1). Discussion Stroke mimics account for 5-30% of “brain attacks.” Of those patients receiving thrombolytic therapy in the Eur- opean Cooperative Acute Stroke Study II (ECASS II), 17% were ultimately shown to not have had strokes [8]. Com- mon conditions such as migraine, epilepsy with and with- out Todd’s paralysis, hypoglycemia, and sinus thrombosis can often mimic stroke [9,10]. Unfortunately, NCCT is not a sensitive radiographic tool in detecting stroke because parenchymal changes do not usually appear early in the course of acute stroke [1,11]. MRI would offer good accuracy and sensitivity in such cases [12]. However, it is often not utilized because of its decreased availability in contrast to the short acquisition time and wide availability for NCCT in the emergency room setting. There are data supporting the use of CT perfusion in acute stroke management [11]. Relative MTT and abso- lute CBV are CT perfusion parameters that help define areas of infarct from areas of penumbra [6]. Its use has also been investigated for the diagnosis of seizures [13,14]. Hauf et al. demonstrated that perfusion CT is a useful tool in accelerating the diagnosis of nonconvul- sive status epilepticus with a sensitivity of 78% [15]. In this case, cortical hyperperfusion was observed as reflected by a decrease in mean transient time (MTT) and a concomitant increase in cerebral blood volume (CBV) and flow (CBF) (Figure 1). This is compatible with previous data demonstrating increased CBV and CBF values in the seizure onset zone as well as in the regions with ictal spread [13]. This hyperperfusion state during the ictal state has also been shown with SPECT and f-MRI in patients with focal epilepsy [16,17]. CT perfusion has the advantages of routine availabil- ity, short acquisition time, and quantitative results. This case further supports the role of CT perfusion in the emergency room setting when assessing stroke patients for thrombolytics. Although patients with stroke mimics infrequently receive thrombolytics and their treatment generally does not lead to harmful complications [18], CT perfusion may spare patients with status epilepticus from the misguided treatment of intravenous thrombo- lysis. PCT may also qualify as a complementary diagnos- tic tool in patients presenting to the emergency room with altered mental status in which stroke is also a con- sideration for etiology. Conclusions In summary, perfusion CT can serve an important role in differentiating acute stroke from an unusual presenta- tion of status epilepticus in the emergency room setting. Page 3 of 4 Consent Written informed consent was obtained from the patient for publication of this case report and any accompany- ing images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Abbreviations NCCT: non-contrast CT head, MTT: mean transit time. CBV: cerebral blood volume, CBF: cerebral blood flow, SPECT: single-photon emission computed tomography, f-MRI: functional magnetic resonance imaging. Acknowledgements Publication of this article was funded in part by the University of Florida Open-Access Publishing Fund. Authors’ contributions WG drafted the manuscript and collected the images and figure utilized in this manuscript. HD edited the manuscript and assisted in CT perfusion image interpretation. SE edited the manuscript as well as supervised. All authors read and approved the final manuscript. Authors’ information WG and HD are both fourth year Neurology residents at the University of Florida. SE is Associate Professor of Neurology, Clinical Director, Adult Neurology Comprehensive Epilepsy Program, and Medical Director, UF & Shands Epilepsy Monitoring Unit. Competing interests The authors declare that they have no competing interests. Received: 7 November 2011 Accepted: 20 January 2012 Published: 20 January 2012 References 1. Davis DP, Robertson T, Imbesi SG: Diffusion-weighted magnetic resonance imaging versus computed tomography in the diagnosis of acute ischemic stroke. J Emerg Med 2006, 31(3):269-277. 2. Scott PA, Silbergleit R: Misdiagnosis of stroke in tissue plasminogen activator-treated patients: characteristics and outcomes. Ann Emerg Med 2003, 42(5):611-618. 3. Selim M, Kumar S, Fink J, Schlaug G, Caplan LR, Linfante I: Seizure at stroke onset: is it an absolute contraindication to thrombolysis. 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