Skip to main content


Log in

Advanced CT for diagnosis of seizure-related stroke mimics

  • Neuro
  • Published:
European Radiology Aims and scope Submit manuscript


Background and purpose

It is assumed that up to 30 % of clinically diagnosed acute ischaemic strokes (AIS) are actually stroke mimics (SM). Our aim was to evaluate the usefulness of advanced CT including CT angiography (CTA) and CT perfusion (CTP) findings when distinguishing AIS from seizure-related SM.


Over a 22-month period data were gathered of patients who presented to our stroke centre with AIS-like symptoms and were examined immediately with an advanced CT, analysed and evaluated by two experienced neuroradiologists who preferred SM rather than AIS. All these patients additionally received electroencephalography and follow-up imaging. CTA was the important feature to exclude vessel occlusion or haemodynamic relevant stenosis. Perfusion patterns were retrospectively analysed qualitatively.


The most common perfusion abnormality was cortical hyperperfusion (22/37 [59.5 %] patients) followed by a hypoperfusion pattern with a cortical-subcortical involvement (15/37 [40.5 %] patients) without evidence of vessel occlusion or stenosis. Seizure-related hyper- and hypoperfusion patterns typically crossed the normal anatomical vascular territories boundaries.


Beyond its use in core and penumbra estimation, advanced CT provides important information to emergency physicians in the difficult clinical diagnosis when differentiating between AIS and seizure-related symptoms with an important impact on therapeutic decision-making.

Key points

• Advanced CT helps to differentiate between ischaemic strokes and stroke mimics.

• Seizure-related perfusion patterns are distinct from ischaemia hypoperfusion.

• Advanced CT could improve rapid adequate treatment for AIS and seizure events.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others


  1. Hand PJ, Kwan J, Lindley RI, Dennis MS, Wardlaw JM (2006) Distinguishing between stroke and mimic at the bedside. Stroke 37:769–775

    Article  PubMed  Google Scholar 

  2. Scott PA, Silbergleit R (2003) Misdiagnosis of stroke in tissue plasminogen activator–treated patients: characteristics and outcomes. Annals of emergency medicine 42:611–618

    Article  PubMed  Google Scholar 

  3. Wintermark M, Luby M, Bornstein NM et al (2015) International survey of acute stroke imaging used to make revascularization treatment decisions. International Journal of Stroke 10:759–762

    Article  PubMed  PubMed Central  Google Scholar 

  4. Campbell BC, Mitchell PJ, Kleinig TJ et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. New England Journal of Medicine 372:1009–1018

    Article  CAS  PubMed  Google Scholar 

  5. Gelfand J, Wintermark M, Josephson S (2010) Cerebral perfusion-CT patterns following seizure. European journal of neurology 17:594–601

    Article  CAS  PubMed  Google Scholar 

  6. Lie C-H, Seifert M, Poggenborg J, Fink GR, Burghaus L (2011) Perfusion computer tomography helps to differentiate seizure and stroke in acute setting. Clin Neurol Neurosurg 113:925–927

    Article  PubMed  Google Scholar 

  7. Mathews MS, Smith WS, Wintermark M, Dillon WP, Binder DK (2008) Local cortical hypoperfusion imaged with CT perfusion during postictal Todd’s paresis. Neuroradiology 50:397–401

    Article  PubMed  Google Scholar 

  8. Hedna VS, Shukla PP, Waters MF (2012) Seizure mimicking stroke: role of CT perfusion. J Clin Imaging Sci 2

  9. Hauf M, Slotboom J, Nirkko A, Von Bredow F, Ozdoba C, Wiest R (2009) Cortical regional hyperperfusion in nonconvulsive status epilepticus measured by dynamic brain perfusion CT. American Journal of Neuroradiology 30:693–698

    Article  CAS  PubMed  Google Scholar 

  10. Hassan AE, Cu SR, Rodriguez GJ, Qureshi AI (2012) Regional cerebral hyperperfusion associated with postictal paresis. Journal of vascular and interventional neurology 5:40

    PubMed  PubMed Central  Google Scholar 

  11. Guerrero WR, Dababneh H, Eisenschenk S (2012) The role of perfusion CT in identifying stroke mimics in the emergency room: a case of status epilepticus presenting with perfusion CT alterations. Int J Emerg Med 5:4

    Article  PubMed  PubMed Central  Google Scholar 

  12. Masterson K, Vargas MI, Delavelle J (2009) Postictal deficit mimicking stroke: role of perfusion CT. J Neuroradiol 36:48–51

    Article  CAS  PubMed  Google Scholar 

  13. Goyal N, Male S, Al Wafai A, Bellamkonda S, Zand R (2015) Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment. Journal of Stroke and Cerebrovascular Diseases 24:828–833

    Article  PubMed  Google Scholar 

  14. Meierkord H, Boon P, Engelsen B et al (2010) EFNS guideline on the management of status epilepticus in adults. European journal of neurology 17:348–355

    Article  CAS  PubMed  Google Scholar 

  15. Sylaja P, Dzialowski I, Krol A, Roy J, Federico P, Demchuk AM (2006) Role of CT angiography in thrombolysis decision-making for patients with presumed seizure at stroke onset. Stroke 37:915–917

    Article  CAS  PubMed  Google Scholar 

  16. Campbell BC, Christensen S, Levi CR et al (2011) Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core. Stroke 42:3435–3440

    Article  PubMed  Google Scholar 

  17. Olivot JM, Mlynash M, Zaharchuk G et al (2009) Perfusion MRI (Tmax and MTT) correlation with xenon CT cerebral blood flow in stroke patients. Neurology 72:1140–1145

    Article  PubMed  PubMed Central  Google Scholar 

  18. Dehkharghani S, Bammer R, Straka M et al (2015) Performance and Predictive Value of a User-Independent Platform for CT Perfusion Analysis: Threshold-Derived Automated Systems Outperform Examiner-Driven Approaches in Outcome Prediction of Acute Ischemic Stroke. AJNR Am J Neuroradiol 36:1419–1425

    Article  CAS  PubMed  Google Scholar 

  19. Lansberg MG, Lee J, Christensen S et al (2011) RAPID automated patient selection for reperfusion therapy: a pooled analysis of the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET) and the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) Study. Stroke 42:1608–1614

    Article  PubMed  PubMed Central  Google Scholar 

  20. Straka M, Albers GW, Bammer R (2010) Real-time diffusion-perfusion mismatch analysis in acute stroke. J Magn Reson Imaging 32:1024–1037

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kudo K, Sasaki M, Yamada K et al (2010) Differences in CT perfusion maps generated by different commercial software: quantitative analysis by using identical source data of acute stroke patients. Radiology 254:200–209

    Article  PubMed  Google Scholar 

  22. Klotz E, Konig M (1999) Perfusion measurements of the brain: using dynamic CT for the quantitative assessment of cerebral ischemia in acute stroke. Eur J Radiol 30:170–184

    Article  CAS  PubMed  Google Scholar 

  23. Koenig M, Kraus M, Theek C, Klotz E, Gehlen W, Heuser L (2001) Quantitative assessment of the ischemic brain by means of perfusion-related parameters derived from perfusion CT. Stroke 32:431–437

    Article  CAS  PubMed  Google Scholar 

  24. Abels B, Klotz E, Tomandl BF, Kloska SP, Lell MM (2010) Perfusion CT in acute ischemic stroke: a qualitative and quantitative comparison of deconvolution and maximum slope approach. AJNR Am J Neuroradiol 31:1690–1698

    Article  CAS  PubMed  Google Scholar 

  25. Wahlgren N, Ahmed N, Dávalos A et al (2007) Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. The Lancet 369:275–282

    Article  CAS  Google Scholar 

  26. Tatu L, Moulin T, Bogousslavsky J, Duvernoy H (1998) Arterial territories of the human brain cerebral hemispheres. Neurology 50:1699–1708

    Article  CAS  PubMed  Google Scholar 

  27. Wintermark M, Flanders AE, Velthuis B et al (2006) Perfusion-CT assessment of infarct core and penumbra receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke. Stroke 37:979–985

    Article  PubMed  Google Scholar 

  28. Radzina M, Krumina G, Kupcs K, Miglane E (2013) Perfusion computed tomography relative threshold values in definition of acute stroke lesions. Acta Radiol Short Rep 2:2047981613486099

    Google Scholar 

  29. Payabvash S, Oswood MC, Truwit CL, McKinney AM (2015) Acute CT perfusion changes in seizure patients presenting to the emergency department with stroke-like symptoms: correlation with clinical and electroencephalography findings. Clin Radiol 70:1136–1143

    Article  CAS  PubMed  Google Scholar 

  30. Ruiz RL, Quintas S, Largo P et al (2017) Utilidad de la tomografía computarizada cerebral multiparamétrica en el diagnóstico diferencial de patología comicial en el código ictus. Estudio preliminar. Neurologia

  31. Kubiak-Balcerewicz K, Fiszer U, Nagańska E et al (2017) Differentiating Stroke and Seizure in Acute Setting—Perfusion Computed Tomography? Journal of Stroke and Cerebrovascular Diseases 26:1321–1327

    Article  PubMed  Google Scholar 

  32. Rupprecht S, Schwab M, Fitzek C, Witte OW, Terborg C, Hagemann G (2010) Hemispheric hypoperfusion in postictal paresis mimics early brain ischemia. Epilepsy research 89:355–359

    Article  PubMed  Google Scholar 

  33. Wiest R, von Bredow F, Schindler K et al (2006) Detection of regional blood perfusion changes in epileptic seizures with dynamic brain perfusion CT—a pilot study. Epilepsy research 72:102–110

    Article  PubMed  Google Scholar 

  34. Masterson K, Vargas M, Delavelle J (2009) Postictal deficit mimicking stroke: role of perfusion CT. Journal of neuroradiology 36:48–51

    Article  CAS  Google Scholar 

  35. Szaflarski JP, Rackley AY, Kleindorfer DO et al (2008) Incidence of seizures in the acute phase of stroke: A population-based study. Epilepsia 49:974–981

    Article  PubMed  PubMed Central  Google Scholar 

Download references


The authors state that this work has not received any funding.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Friederike Austein.

Ethics declarations


The scientific guarantor of this publication is Thomas Lindner.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise. No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was not required for this study because of the retrospective anonymous data analysing without any impact to therapy decision making.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• diagnostic

• performed at one institution

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Austein, F., Huhndorf, M., Meyne, J. et al. Advanced CT for diagnosis of seizure-related stroke mimics. Eur Radiol 28, 1791–1800 (2018).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: