Diagnostic Puzzle of Acute Ischemic Stroke Mimics - Seizure Versus Post-Stroke Recrudescence: A Case Report.

BACKGROUND Focal seizure with impaired awareness, post-seizure Todd's phenomenon, and post-stroke recrudescence can all present with focal neurological deficits, mimicking stroke. As acute ischemic stroke mimics, they are distractors in the emergency setting where management is time-sensitive both for seizure and stroke. Nevertheless, a timely diagnosis can be made with exploration of the clinical features supported by investigation such as computerized tomographic perfusion. CASE REPORT Our patient was a 65-year-old woman who was known hypertensive, with type 2 diabetes mellitus, and previous intracerebral hemorrhage with minimal right-sided residual deficits, but still able to ambulate independently. She was brought to the Emergency Department because 1 hour prior to presentation, she had sudden worsening of weakness of the right limbs, aphasia, aggression, and confusion. An initial impression of repeat acute stroke, focal seizure with impaired awareness, Todd's phenomenon, and post-stroke recrudescence was considered. While CT angiography was suggestive of left middle cerebral artery occlusion, CT perfusion revealed extensive hypoperfusion patterns beyond the region of the occlusion, thus suggesting a different etiology from acute ischemic stroke. In view of her previous left hemispheric lesion coupled with the presentation, our working diagnosis was seizure with Todd's phenomenon, and she was started on an anti-epileptic drug. Her condition returned to baseline within 24 h of admission and was subsequently discharged. CONCLUSIONS Our case demonstrates that adequate elucidation of clinical features in conjunction with CT perfusion, as a dual-purpose tool, can aid the diagnosis of both stroke mimics and acute ischemic stroke in the Emergency Department where rapid treatment is essential.

Triple emergencies: Hyperosmolar hyperglycemic state, venous thromboembolism, and huge free-floating right heart thrombus successfully managed with anticoagulation.

A 57-year-old man, with type 2 diabetes mellitus, was admitted with a hyperosmolar hyperglycemic state, who developed in-hospital venous thromboembolism with huge free-floating right heart thrombus, and there is no available optimal treatment option for the huge free-floating right heart thrombus, except anticoagulation with warfarin and low molecular weight heparin with successful outcome.

Ebstein's Anomaly: An Unanticipated Differential Diagnosis of Egg-on-Stick Appearance and the Diagnostic Dilemma.

BACKGROUND Ebstein's anomaly (EA) is a rare congenital cardiac abnormality with diverse anatomic and spectra of clinical presentations. This heart anomaly occurs in approximately 1 per 200 000 live births and accounts for <1% of congenital cardiac diseases. The main pathologic finding is "atrialization" of the basal region of the right ventricle. EA has been described extensively in the literature; however, to the best of our knowledge, this is the first reported case of EA presenting with "egg-on-stick" appearance. CASE REPORT A 42-year-old woman presented on account of 2 years of progressive abdominal swelling, early satiety, and progressive weight loss. There was an associated history of dyspnea on exertion, easy fatigability, paroxysmal nocturnal dyspnea, and orthopnea. General examination revealed egg-on-stick appearance: visible distended abdominal wall veins and massive ascites with no pedal edema. Overall, pertinent cardiovascular examination findings and echocardiographic features are in keeping with EA. CONCLUSIONS We present the likely first case of egg-on-stick appearance as part of the presentation of EA, which posed a diagnostic dilemma. Echocardiography can help in unraveling this dilemma.