Introduction: Stroke mimics often present similarly to acute ischemic stroke, yet have markedly different causes, management strategies, and outcomes. We report a diagnostically complex case that convincingly resembles a right middle cerebral artery (MCA) syndrome, only for subsequent findings to contradict that impression. Case Presentation: A 78-year-old man with vascular risk factors developed acute confusion, gait instability, right gaze preference, left-sided neglect, and mild left hemiparesis (NIHSS = 9). Non-contrast CT and CT angiography (CTA) revealed no hemorrhage or large-vessel occlusion. MRI on hospital days 2 and 4 showed no diffusion-restricted lesion, and CT perfusion was unremarkable. EEG demonstrated focal right-hemispheric slowing without epileptiform discharges. The patient exhibited striking improvement after initiation of levetiracetam, and later, additional cognitive gains after empiric thiamine for alcohol use. Lumbar puncture revealed elevated cerebrospinal fluid (CSF) protein (114 mg/dL) and glucose (71 mg/dL), with a normal nucleated cell count (1 CU MM). Infectious and paraneoplastic panels were negative, and cytology revealed no malignant cells. CT chest/abdomen/pelvis showed no malignancy but noted an indeterminate adrenal lesion, with a follow-up MRI abdomen characterizing the lesion as an adrenal adenoma. Conclusion: The case demonstrates diagnostic tension between clinical certainty and evolving data. Serial negative MRI and rapid improvement on levetiracetam and thiamine challenged the presumed stroke diagnosis, while elevated CSF protein raised the possibility of an autoimmune or paraneoplastic process. This overlap between seizure-related deficits, thiamine deficiency, and potential paraneoplastic encephalopathy is rarely reported and underscores the need for flexible reasoning in “stroke mimic” presentations. When a textbook focal neurological syndrome is unconfirmed by imaging, clinicians should maintain a broad differential including seizure-related and immune-mediated etiologies. Empiric antiseizure therapy and thiamine can be both diagnostic and therapeutic. CSF analysis remains indispensable in uncovering occult autoimmune or paraneoplastic pathology.
Introduction: Guillain-Barré syndrome (GBS) is an autoimmune polyradiculoneuropathy often involving cranial nerves and the autonomic nervous system. Autoimmune encephalitis (AE) encompasses immune-mediated inflammatory brain disorders. The co-occurrence of GBS and AE is rare. Case Presentation: We present a case of seizure onset followed by progressive limb weakness, autonomic dysfunction, behavioral changes, and impaired consciousness. Cerebrospinal fluid showed albuminocytological dissociation, and electromyography revealed combined motor axonal and demyelinating features. Diagnosed with GBS and AE, the patient deteriorated requiring intubation, but improved significantly after Protein A immunoadsorption, steroid pulse therapy, and anti-infective treatment, successfully weaning from ventilation with regained muscle strength and mental function. Conclusion: In severe GBS with overlapping AE, timely immunoadsorption can achieve favorable prognosis.
Introduction: Pulmonary pleomorphic carcinoma is a rare, highly aggressive subtype of lung cancer with frequent early multiple-organ metastases including to the brain. However, brain metastases that precede detection of a primary lung lesion are exceedingly rare. We report a case of pulmonary pleomorphic carcinoma with brain metastasis that was initially diagnosed and treated as glioblastoma. Case Presentation: A 69-year-old man presented with left-sided spatial neglect and abnormal behaviors. Brain computed tomography revealed a right temporal-subcortical hemorrhage. The patient subsequently underwent right temporal craniotomy and hematoma evacuation surgery. Histopathological examination revealed markedly large atypical cells with necrosis. Immunohistochemistry revealed focal GFAP positivity. As no primary lesion was detected on systemic computed tomography, the patient was diagnosed with glioblastoma, IDH-wildtype, and temozolomide was initiated. Without a significant recurrence of the brain lesion, the patient’s condition deteriorated. Follow-up computed tomography revealed new mass lesions in the lungs and small intestine. The patient died of peritonitis secondary to small intestinal perforation. Autopsy revealed a large mass in the right lung that extended to the mediastinum and small daughter lesions in multiple organs, including the small intestinal mesentery. The known brain tumor and trunk tumors showed similar histology and strong immunohistochemical positivity for cytokeratin 7. Conclusion: This case illustrates that metastatic pulmonary pleomorphic carcinoma may mimic glioblastoma both radiologically and histopathologically, particularly when the primary tumor remains undetected. When brain metastasis cannot be confidently excluded during the evaluation of a brain tumor, re-evaluation of histopathological and neuroimaging findings, together with repeated systemic evaluation at short intervals, is important for establishing an accurate diagnosis.
We read with interest the paper by Bahrami et al. describing a patient who experienced an episode of transient global amnesia (TGA) in the context of migraine with aura, presumed to be the precipitating event. This clinical report prompted the authors to review the concept of “migramnesia” [1].
Introduction: Intraorbital arteriovenous fistula (IOAVF) is a rare vascular anomaly characterized by a direct arteriovenous shunt within the orbit, often presenting with orbital congestion, proptosis, and ocular pain. Fewer than 50 cases have been documented in the literature. Unlike carotid-cavernous fistulas, IOAVFs are supplied by branches of the ophthalmic and internal maxillary arteries, draining through orbital veins into the facial vein without direct cavernous sinus involvement. Accurate diagnosis through digital subtraction angiography (DSA) is essential for treatment planning, as noninvasive imaging may miss the subtle intraorbital shunt. Case Presentation: A 60-year-old woman presented with progressive right eye proptosis, conjunctival congestion, and ocular pain. DSA confirmed a right IOAVF fed by branches of the ophthalmic and internal maxillary arteries, draining into the facial vein via dilated ophthalmic veins. The patient underwent a transvenous endovascular approach: a microcatheter was navigated through the facial and ophthalmic veins to the fistula site, where five detachable coils (Numen™ Silk coils; MicroPort NeuroTech, Shanghai, China) were deployed, followed by 0.5 mL of Squid 18 liquid embolic agent (Balt Extrusion, Montmorency, France). The combined coil-liquid technique achieved complete occlusion of the fistula in a single session. The patient’s symptoms resolved, vision improved, and follow-up imaging showed no residual shunt. Conclusion: This case demonstrates the efficacy of a tailored transvenous embolization strategy using coils and Squid 18 in the definitive treatment of IOAVFs. This approach provides an effective, minimally invasive treatment for IOAVF and highlights the importance of timely diagnosis and individualized treatment strategies.
