Abstract:

Objective To examine the clinical characteristics and diagnostic-therapeutic approach for young-onset stroke presenting as seizure-like episodes, with the aim of aiding clinicians in accurate diagnosis and reducing the risk of misdiagnosis. Methods We retrospectively analyzed the diagnostic and treatment course of a single case of young stroke that began with seizure-like activity and performed a literature review of related reports. Results The patient was a 19-year-old male admitted for generalized convulsions with impaired consciousness lasting 5 hours. The event began during sleep with sudden convulsions and loss of consciousness, characterized by bilateral upper limb extension, bilateral lower limb flexion and tremor, clenched jaw, and tongue/cheek bite. The convulsive episode self-limited after approximately 10 minutes, but the altered consciousness persisted. The patient had a recent history of fever following an upper respiratory tract infection. Initial cranial CT showed no parenchymal lesion. Cerebrospinal fluid (CSF) routine testing, biochemistry, acid-fast and India ink stains were unremarkable; CSF metagenomic next-generation sequencing (PIM) was negative. Continuous video EEG did not reveal epileptiform discharges. On hospital day 2, repeat head CT raised suspicion for basilar artery occlusion; subsequent digital subtraction angiography confirmed occlusion of the mid-upper basilar artery. The patient underwent percutaneous superselective endovascular thrombectomy. At discharge he was in a minimally conscious state; at 1-year follow-up he had regained clear consciousness. Conclusion Seizure-like events may clinically mimic decerebrate rigidity and sympathetic overactivity, particularly in young patients without head trauma or conventional cerebrovascular risk factors. When new-onset seizure-like episodes (especially those preceded or accompanied by infection) are associated with abnormal neuroimaging, clinicians should actively pursue vascular and other etiologies to avoid misdiagnosis or delayed diagnosis. Prompt identification and timely intervention can improve patient outcomes.

Key words: stroke, epilepsy, paroxysmal sympathetic hyperactivity, decerebrate rigidity