Abstract Background and aims Stroke mimics pose a diagnostic challenge in acute stroke care, including migraine aura, Todd’s paresis, and functional neurological symptoms. In acute ischemic stroke, functional symptoms may coexist, sometimes constituting the predominant presentation, and may not correspond to the lesion’s topography. This can delay diagnosis and treatment, demand further work-up, and prolong hospitalization, raising healthcare costs. We present a single-center retrospective series of five patients with functional symptoms at admission, later diagnosed with anterior cerebral artery (ACA) territory ischemic strokes. Methods Patients were mostly female (n=4, 80%), aged 54–87 years, with hypertension (n=4, 80%), dyslipidemia (n=4, 80%), smoking (n=2, 40%), and anxiety disorders (n=5, 100%). Initial non-contrast CT was normal in most (n=4, 80%). Admission features included inconsistent muscle weakness (n=5, 100%), oppositional paratonia (n=2, 40%), stereotyped involuntary movements (n=2, 40%), palpitations (n=1, 20%), numbness (n=1, 20%), headache (n=1, 20%), and mutism (n=1, 20%). Three patients exhibited Hoover’s sign. Results Median time to neurological evaluation was 4 hours (IQR 5). Functional neurological disorder was initially suspected in all cases. Only one patient received thrombolysis. All underwent extended workup (brain MRI, EEG, echocardiogram, 24h Holter), leading to prolonged hospitalization (median 23 days, IQR 8). Most patients (n=4, 80%) were discharged with modified Rankin Scale ≥2. Conclusions Functional symptoms can accompany ACA ischemic strokes, including inconsistent muscle weakness, oppositional limb posturing, and involuntary stereotyped movements. Their coexistence contributes to diagnostic errors, low thrombolysis rates, and prolonged hospitalization. Awareness of these presentations is essential for timely recognition and management of ACA territory strokes. Conflict of interest Artur Nascimento: nothing to disclose. André Rêgo: nothing to disclose.
Nascimento et al. (Fri,) studied this question.