When Time Precludes Certainty: Intravenous Tenecteplase for Acute Global Aphasia in a Young Woman Along With Post-acute Diagnostic Reorientation

Stroke mimics represent a major diagnostic challenge in the hyperacute setting. We report the case of a 29-year-old woman with no prior documented history of migraine or clinically significant headache who developed sudden-onset bradylalia and right hemisensory paresthesias, rapidly progressing to severe mixed aphasia with motor predominance, jargonaphasia, anomia, dysgraphia, alexia, and involuntary mixing of three languages. The initial National Institutes of Health Stroke Scale (NIHSS) score was five, accompanied by headache and vomiting. Intense agitation required procedural sedation for CT acquisition. Motion artifact rendered perfusion maps non-interpretable. Non-contrast CT showed no hemorrhage or established infarct (Alberta stroke programme early CT score (ASPECTS) 10), and CT angiography demonstrated no large vessel occlusion. Given the disabling neurological deficit and symptom onset within the therapeutic window, intravenous tenecteplase 17.5 mg was administered. Neurological recovery was complete within hours, and the delayed brain MRI was normal. Headache with Neurological Deficits and Cerebrospinal Fluid Lymphocytosis (HaNDL) syndrome remained an unconfirmed diagnostic consideration. Ultimately, the episode was assessed as a probable stroke mimic, most consistent with migraine with aphasic aura. This case illustrates that intravenous thrombolysis may be clinically justifiable under reasonable diagnostic uncertainty when the deficit is severe, the therapeutic window is favorable, and imaging is technically limited, followed by cautious post-acute diagnostic reorientation.