By Katherine Anderson
Radiologists are central to recognizing vascular red flags that mimic stroke in the emergency setting.
Symptoms such as sudden weakness, difficulty speaking, vision changes or headache may initially seem indicative of a stroke, but they can also signal a multitude of other vascular pathologies.
“While vascular imaging education often centers on ischemic stroke, many other acute vascular conditions can mimic or overlap with stroke presentations,” according to Hediyeh Baradaran, MD, MS, chief of neuroradiology and associate professor at Columbia University in New York.
As CT angiography (CTA) of the head and neck becomes one of the fastest-growing imaging studies ordered in emergency departments, radiologists are encountering a broader range of vascular findings, some with urgent clinical implications.
Focusing on diagnostic awareness beyond the typical ischemic spectrum is critical.“Early detection of these vascular abnormalities can be lifesaving. Many of these findings, though subtle, may indicate the need for further imaging, subspecialist consultation or urgent intervention.”
Hediyeh Baradaran, MD, MS
Key red flags that may point to alternative diagnoses include imaging clues suggestive of vasculitis, venous thrombosis or vascular malformations—all of which can closely mimic stroke clinically. Dr. Baradaran emphasizes maintaining a systematic approach to identifying the “something’s not right” moments.
Dr. Baradaran presented the case of a young male patient who arrived in the ED with acute left-sided neck pain. Imaging revealed a subtle but important finding: eccentric soft-tissue thickening along the posterior wall of the proximal internal carotid artery. This appearance was consistent with transient perivascular inflammation of the carotid artery (TIPIC) syndrome—an often under-recognized condition that can be mistaken for soft, non-calcified plaque or early dissection. Key imaging criteria for TIPIC include eccentric perivascular inflammation and the exclusion of other vascular or nonvascular causes.
In another case, a scattered sulcal hemorrhage initially suggested vasculitis, but CTA and follow-up imaging demonstrated reversible vasoconstriction—ultimately diagnosed as reversible cerebral vasoconstriction syndrome (RCVS). A hallmark symptom of RCVS is a thunderclap headache.
These cases, and others covered in the session, highlight how dynamic vascular changes can closely mimic stroke and why a systematic approach is essential. Dr. Baradaran noted that careful attention to hemorrhage patterns on CT can provide valuable clues of localizing culprit aneurysms, while even subtle vascular irregularities may carry significant clinical implications.
She stressed that a wide range of non-ischemic vascular pathologies can present with overlapping features, underscoring the need for a broad, thoughtful approach to vascular imaging.
“Early detection of these vascular abnormalities can be lifesaving. Many of these findings, though subtle, may indicate the need for further imaging, subspecialist consultation or urgent intervention,” Dr. Baradaran said. “Timely recognition allows for more accurate diagnosis, helps avoid mismanagement and ensures that patients receive the most appropriate care pathway from the outset.”
Access the presentation, “It's Not a Stroke: What Else can Go Wrong with the Arterial Vasculature?” (T6-CNR04B) on demand at RSNA.org/MeetingCentral
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The RSNA 2025 Daily Bulletin is the official publication of the 110th Scientific Assembly and Annual Meeting of the Radiological Society of North America. Published online Sunday, November 30 — Thursday, December 4.
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