Abstract 168: A Case of Large Vessel Occlusion Presenting as a New‐Onset Focal Seizure

Introduction Hemiparesis after a new onset seizure was originally considered a contraindication to lytic administration to avoid the hemorrhagic risk associated with thrombolysis in patients experiencing post‐ictal Todd's paralysis [1]. However, the observation window required to establish an improved diagnosis of a post‐ictal Todd's paralysis runs counter to the rapid treatment requirements for acute ischemic stroke. Seizure at stroke onset is a recognized but poorly studied phenomenon, and presents a critical diagnostic dilemma to patients in the hyper‐acute window, requiring rapid triage to a seizure vs a stroke treatment pathway. Methods Here we present a case of a 73‐year‐old woman with pancreatic cancer who developed focal status epilepticus due to an emergent large vessel occlusion (LVO). Results Patient is a 73‐year‐old woman with metastatic pancreatic cancer and a recent stroke taking aspirin and Plavix who initially presented to the emergency department with the concern for an NSTEMI. She was admitted to the medicine service and treated with a heparin drip. On day 7 a stroke code was called as the patient was unresponsive and had tonic activity on the right side of her body. Her NIHSS was 26 for decreased level of consciousness and intermittent right hemiparesis. She was given Ativan, Versed, loaded with Vimpat to control the seizures without success, and ultimately intubated and taken for a stat CT head and CT angiography. This showed a left distal ICA occlusion. She was taken for emergent thrombectomy with TICI IIb revascularization. The patient was placed on video EEG showing severe slowing of background with no epileptiform abnormalities. Her transthoracic echocardiogram had moderate left atrium dilatation but was otherwise unremarkable. MRI brain without contrast presented a large left MCA acute ischemic stroke. The patient continued to have a poor hospital course and had persistent deficits from her left MCA territory stroke. Due to her poor prognosis from her pancreatic cancer and her deficits from her large left MCA stroke, comfort measures were pursued. The patient was pronounced deceased 11 days after being in the hospital. The reason for the stroke was determined to be a malignancy‐associated embolism. Conclusions Seizure stroke onset is a known presentation of a stroke but is poorly studied and under‐recognized [2]. The purpose of our report is to raise awareness of this presentation, particularly in patients with no history of epilepsy and with significant vascular risk factors presenting with new‐onset seizures with persistent localizable deficits. We would recommend CT angiography as the first imaging study in these patients rather than plain CT, with a low threshold to treat with thrombolytic if an alternative cause is not found and the patient is otherwise a candidate, or endovascular therapy in the instance of LVO, as in our case.