Case Presentation: A 40-year-old Caucasian male presented with a recent diagnosis of stage IV metastatic duodenal adenocarcinoma. Given the metastatic disease, after duodenal stent placement, the patient started on adjuvant mFOLFOX6 chemotherapy. During the second day of the first cycle of chemotherapy, the patient suddenly experienced complete right-sided weakness, headache, confusion, and slurred speech. He was oriented to person and place but was not oriented to time. Vital signs were within normal limits. On physical examination, the patient was mildly somnolent with right-sided hemiplegia and mild to moderate dysarthria. His National Institutes of Health Stroke Scale (NIHSS) score was 6. The initial CT head and MRI Brain showed no acute infarction, intracranial hemorrhage, or mass effect. CT angiography of the head and neck demonstrated no significant stenosis or vascular occlusion. We proceeded with cerebral perfusion study, which was revealed asymmetrically decreased cerebral blood flow and prolongation of time parameters involving portions of the left frontal, parietal, and posterior left temporal lobes and to a lesser degree left frontal operculum, following a watershed distribution. There was no evidence of corresponding decreased cerebral blood volume, and this perfusion abnormality represented potentially reversible ischemia due to transient vasospasm. 5-FU infusion was discontinued, and the patient’s neurologic symptoms were completely resolved with conservative management in 24 hours. We diagnosed the patient with 5-FU-induced acute transient cerebral vasospasms with an acute stroke-like presentation. The second cycle of mFOLFOX6 chemotherapy was given with verapamil pre-treatment, with no further neurologic phenomena observed after treatment
Discussion: Modified FOLFOX6 (mFOLFOX6) chemotherapy ( oxaliplatin plus infusional fluorouracil (5-FU), and leucovorin) is the most chosen option in patients with advanced small bowel adenocarcinoma (1). Cerebral vasospasm with associated transient ischemia is a rarely encountered adverse effect of the 5-FU. In the current literature, there are only a few cases reporting a stroke-like presentation caused by the 5-FU component (2-4). Differentiating stroke mimics from real stroke is crucial due to the acuity of the diagnosis for thrombolytic therapy. Unfortunately, in the literature, 21% of stroke mimics are treated inappropriately with thrombolytics (5).
Conclusions: We suggest that 5-FU induced cerebral vasospasm can present with acute stroke-like symptoms, and physicians should be aware of stroke mimics as a differential diagnosis to spare their patients from unnecessary invasive and high-risk treatments.