Transient Neurological Deficit Due to Intracerebral Hemorrhage: A Diagnostic Pitfall Mimicking a Transient Ischemic Attack.

Intracerebral hemorrhage (ICH) is a severe and potentially fatal subtype of stroke that typically presents with persistent or worsening neurological deficits. In contrast, transient neurological deficits are commonly attributed to transient ischemic attacks (TIAs). As a result, many clinicians initiate antiplatelet therapy without prior brain imaging, especially in settings with limited resources. However, this approach may lead to misdiagnosis and inappropriate treatment in rare cases where ICH mimics a TIA. A 64-year-old man with a history of hypertension presented with sudden-onset left-sided weakness and slurred speech lasting one hour, which resolved spontaneously. He had no history of trauma, substance use, or antithrombotic therapy. On admission, neurological deficits were improving, with limb power returning to normal within 15 minutes. Initial clinical assessment suggested a transient ischemic attack (TIA), but a non-contrast computed tomography (CT) scan of the brain revealed a small intracerebral hemorrhage in the right basal ganglia. This case highlights the diagnostic challenge of distinguishing TIA from ICH based solely on clinical presentation. Although uncommon, ICH can occasionally manifest with transient neurological symptoms, closely mimicking ischemic events. In such scenarios, initiating antithrombotic therapy without imaging carries the potential risk of hematoma expansion. Recommendations regarding brain imaging in suspected TIA differ across expert bodies, while some advocate early neuroimaging in all patients presenting with transient neurological symptoms, others recommend a more selective approach based on the clinical suspicion of alternative diagnoses. These differences may reflect variations in healthcare systems and underscore the importance of applying clinical judgment. This case underscores the importance of considering ICH in the differential diagnosis of transient neurological symptoms. It advocates for early brain imaging, preferably before starting antiplatelet therapy, in all patients with suspected TIA, to ensure safe and appropriate management. Greater clinical vigilance and imaging access are essential to prevent misdiagnosis and improve outcomes in such atypical presentations.