Introduction:- Stroke is a common and serious disorder, with an incidence of 795 000 each year in the United States alone. Worldwide, stroke is a leading cause of death and disability. Recombinant tissue plasminogen activator rtPA ) was approved a decade ago for the treatment of acute ischemic stroke. The guidelines for its use include stroke onset within 3 4.5 hours of intravenous drug administration, preceded by a computed tomographic (CT) scan to exclude the presence of hemorrhage, which is a contraindication to the use of the drug. Aims/Objectives:- The importance of MRI/CT perfusion of brain in radiographic evaluation of stroke. Materials / Methods:- A 27 year old male patient was brought to the ED following an episode of new onset of seizure 20 minutes before coming to ED. History of headache, dizziness was there since last 3 hours. Patient had a patent airway, RR of 12, pupils BERL 3mm, GCS 7/15. Vitals included HR 120/min, BP 150/80 mm Hg, RBS 162 mg/dl. Secondary survey was normal except CNS. Patient was in post ictal phase. So, differentials at this point were metabolic causes of seizure /space occupying lesion/stroke with new onset of seizure. After IV cannulation, samples collected for basic blood investigations. One episode of GTCS was witnessed in the ED which was controlled by IV Lorazepam 2 mg and then loaded with IV Fosphenytoin 1.5 gm over 20 minutes. Urgent MRA brain and neck was suggestive of acute non hemorrhagic right MCA infarcts with thrombus in right carotid bulb and in the main stem division of right MCA. From the details of sequence of events, patient was considered in window period for thrombolysis. After ruling out contraindications for thrombolysis , decision for thrombolysis was taken. Patient was thrombolysed by Inj. Alteplase 70 mg IV. CBC, S. electrolytes, S. creatinine were within normal limits. ECG showed sinus tachycardia. Results:- Seizure at onset has been considered a relative contraindication for intravenous thrombolysis in patients with acute ischemic stroke. Todd's paralysis is a neurological condition experienced by individuals with epilepsy, in which a seizure is followed by a brief period of temporary paralysis The paralysis may be partial or complete but usually occurs on just one side of the body. In our case, urgent MRA brain and neck was suggestive of acute non hemorrhagic right MCA infarcts with thrombus in right carotid bulb and in the main stem division of right MCA from the details of sequence of events, patient was considered in window period for thrombolysis and was given TPA after ruling out contraindications This would have not been possible with CT brain without perfusion (as per the current AHA guidelines) Discussion:- Differentiation between stroke and stroke mimic can be a clinically arduous task for both emergency physicians and neurologist . Hence, imaging may be critical in making a diagnosis of stroke in an acute setting. Post seizure palsy (Todd’s Palsy) is one condition that can mimic stroke. CT Brain is currently recommended imaging as per current AHA guidelines for diagnosing stroke by excluding intracranial hemorrhage prior to administration of intravenous thrombolysis. However, it has a limited role in differentiating those patients of stroke from stroke mimic. Conclusion:- This case report emphasizes on MRI/CT perfusion of brain as modality of choice over plain CT brain. Since as per current AHA guidelines seizure at onset of stoke is considered contraindication to IV thrombolysis with suspicion of Todd’s palsy. MRI/CT Perfusion can overcome this by accurately diagnosing stroke and ruling out Todd’s palsy as stroke mimic.
Keywords: Imaging in stroke, Todd's paralysis.