2024 American Academy of Neurology Abstract Website

Objective:

To describe several cases of sudden onset aphasia and alexia without agraphia initially treated as stroke/transient ischemic attack (TIA), later diagnosed as glioblastoma.

Background:

Fewer than 30% of sudden onset neurological deficits are eventually diagnosed with stroke. Such cases are due to stroke mimics, including seizure. Gliomas can be misdiagnosed initially as stroke both clinically and radiographically.

Design/Methods:

N/A

Results:

A 58-year-old female presents with episodic speech arrest. Initial MRI imaging noted a left frontal enhancing mass lesion. Upon review, multidisciplinary teams felt this was “an old stroke remnant.” Dual antiplatelet therapy was prescribed. Initial EEG without event capture was negative. 2 months after discharge, she developed episodic right peri-oral, finger, and ankle numbness. Repeat MRI revealed left frontal mass enlargement. Partial resection revealed glioblastoma.

A 76-year-old male presents with aphasia and alexia without agraphia to an outside hospital. tPA was administered. MRI revealed diffusion restriction and left temporal lobe/posterior insula hyperintensity with edema. A diagnosis of stroke was made. 3 months later, the alexia reappeared. MRI showed increasing enhancement. MRI-SPECT scan showed increased choline:NAA ratio. Biopsy revealed glioblastoma.

A 64- year-old male presents with "word salad.” The diagnosis was MRI-negative stroke. Examination revealed alexia without agraphia. TPA was administered. 2 months after discharge, with persistent alexia, he developed increased forgetfulness. Repeat imaging revealed a new enhancing mass in the anterior corpus callosum and lesions in the medial temporal lobe. Biopsy revealed glioblastoma.

Conclusions:

Glioblastomas mimicking sudden onset vascular events and radiographic signatures mimicking stroke can lead to misdiagnoses. We postulate that in all three cases, a focal seizure arising out of the angular gyrus of the left parietal lobe was the underlying mechanism. Ictal aphasia is rare as is alexia without agraphia. They underscore the need for more refined clinical assessments, EEG monitoring and imaging diagnostics to prevent diagnostic errors and treatment delays.