Virginia Via Research Day Book 2026

Medical Student Research Case Reports

08 A STROKE MIMIC WITH PARADOXICAL GAZE PREFERENCE, ELEVATED CEREBROSPINAL FLUID PROTEIN, AND RESPONSE TO LEVETIRACETAM AND THIAMINE: A DIAGNOSTIC CHALLENGE AND REVIEW

Yash Desai, OMS-IV, Prutha Patel, OMS-IV, Rehab Abdin, MD, Rahul Muchintala, MD, Jote Limeneh, MD, Andrew Mangano, DO, MBA, FHM, FACP Corresponding author: ydesai@vcom.edu

Mary Washington Healthcare, Fredericksburg, Virginia

localizing exam and paradoxical combination of gaze preference and weakness were not typical for metabolic or postictal presentations described in prior reports. The elevated CSF protein with minimal pleocytosis resembled patterns reported in early or seronegative autoimmune or paraneoplastic syndromes. Graus et al. note that CSF inflammatory changes are common in early autoimmune or paraneoplastic neurologic syndromes, even when MRI and antibody testing are nondiagnostic. At the same time, his rapid clinical improvement is not characteristic of most autoimmune syndromes, making his course somewhat distinct and suggestive of a mixed or evolving process. Diagnosis: Acute stroke mimic most consistent with focal seizure-related cortical dysfunction with contribution from thiamine deficiency, alongside CSF findings raising concern for an early or seronegative autoimmune or paraneoplastic encephalopathy. IRB Statement: This case meets institutional criteria for IRB exemption as a single-patient case report with de identified information.

cognitive gains after high-dose parenteral thiamine. CSF revealed markedly elevated protein (114 mg/dL) with 1 WBC/µL, and infectious and paraneoplastic panels were negative. Imaging of the chest, abdomen, and pelvis revealed an indeterminate adrenal lesion later characterized as a benign adenoma. He was discharged to acute rehabilitation with near-complete resolution of motor deficits but persistent cognitive impairment. Methods: To contextualize this case, we searched PubMed and Google Scholar using the terms stroke mimic, nonconvulsive seizure, albuminocytologic dissociation, autoimmune encephalitis, and paraneoplastic neurologic syndrome. Sources included observational studies, case reports, and reviews describing acute focal deficits with normal DWI, elevated CSF protein, or mixed metabolic and immune presentations. Articles informing this comparison included large stroke mimic cohort studies, literature on postictal focal deficits, Wernicke-associated neurological findings, and reviews of autoimmune and paraneoplastic encephalitides. Comments: Compared with the literature, this patient shared several features seen in common stroke mimics, particularly the improvement after levetiracetam and the history of heavy alcohol use, both of which can produce reversible deficits. However, the sharply

Context: Stroke mimics continue to account for a substantial portion of emergency stroke evaluations, even when the neurological exam appears localizing. Seizure, metabolic encephalopathy, and autoimmune or paraneoplastic disorders can all produce transient deficits that resemble an acute ischemic stroke. This case describes an elderly man whose presentation strongly suggested a right MCA infarct, yet every major diagnostic test pulled the picture in a different direction. His rapid response to levetiracetam and thiamine, paired with cerebrospinal fluid (CSF) albuminocytologic dissociation, raised the possibility of overlapping mechanisms rather than a single unifying diagnosis. Report of Case: A 78-year-old man with hypertension, diabetes, hyperlipidemia, prior NSTEMI, chronic hypercalcemia, and heavy alcohol use was brought in for acute confusion and unsteadiness. Examination revealed right gaze preference, left-sided neglect, and mild left hemiparesis (NIHSS 9), a pattern entirely consistent with a right MCA syndrome. CT and CTA showed no hemorrhage or large-vessel occlusion. MRI on hospital days 2 and 4 remained negative for acute infarct, and CT perfusion was also normal. EEG demonstrated right-hemispheric slowing without epileptiform discharges. He improved substantially after starting levetiracetam and later showed additional

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2026 Research Recognition Day