Arokszallasi et al. BMC Neurology
(2019) 19:14
https://doi.org/10.1186/s12883-019-1241-6

CASE REPORT

Open Access

Acute alcohol intoxication may cause delay
in stroke treatment – case reports
Tamas Arokszallasi1*, Eszter Balogh1, Laszlo Csiba1,2, Istvan Fekete1, Klara Fekete1 and Laszlo Olah1

Abstract
Background: The signs and symptoms of acute alcohol intoxication resemble those of vertebrobasilar stroke. Due
to their shared symptoms including double vision, nystagmus, dysarthria, and ataxia, the differential diagnosis of
alcohol intoxication and vertebrobasilar stroke may pose a challenge. Moreover, if alcohol intoxication and stroke
occur simultaneously, the signs and symptoms of stroke may be attributed to the effects of alcohol, leading to
delayed stroke diagnosis and failure to perform reperfusion therapy.
Case presentations: Three cases of alcohol intoxication and stroke are presented. The first patient (female, 50 years
old) had dysarthria, nystagmus and trunk ataxia on admission. Her blood alcohol level was 2.3‰. The symptoms
improved after forced diuresis, but 5.5 h later progression was observed, and the patient developed diplopia and
dysphagia in addition to her initial symptoms. Angiography showed occlusion of the basilar artery. Intraarterial
thrombolysis was performed. The second patient (male, 62 years old) developed diplopia, dysarthria and trunk
ataxia after consuming 4-units of alcohol, and his symptoms were attributed to alcohol intoxication. Two hours
later, neurological examination revealed dysphagia and mild right-sided hemiparesis, which questioned the causal
relationship between the symptoms and alcohol consumption. Cerebral CT was negative, and intravenous
thrombolysis was administered. The third patient (male, 55 years old) consumed 10 units of alcohol before falling
asleep. Three hours later, his relatives tried to wake him up. He was unresponsive, which was attributed to alcohol
intoxication. When he woke up 8 h later, right-sided hemiparesis and aphasia were observed, and cerebral CT
already revealed irreversible ischemic changes.
Conclusions: Our cases show that alcohol consumption may interfere with stroke diagnosis by mimicking the signs
and symptoms of vertebrobasilar stroke. Moreover, attributing the symptoms of stroke to alcohol intoxication may
delay stroke diagnosis resulting in failure of reperfusion therapy. Based on our observations we conclude that stroke
should be considered in the case of worsening symptoms, dysphagia, hemiparesis and disproportionately severe
signs that cannot be attributed to the amount of alcohol consumed. In the case of ambiguity, ambulance should
be called, and if stroke cannot be excluded, specific therapy should be administered.
Keywords: Alcohol intoxication, Stroke, Thrombolytic therapy, Diagnostic errors

Background
Among patients presenting with acute neurological
symptoms, it is crucial to decide in time whether they
suffer from ischemic stroke and whether they are eligible
for intravenous tissue plasminogen activator (IV tPA)
treatment [1]. The short time window, however, may not
always allow neurologists to establish a correct diagnosis, therefore it may be difficult to determine whether
* Correspondence: aroksztamas@gmail.com
1
Department of Neurology, Faculty of Medicine, University of Debrecen,
Moricz Zs. krt 22, Debrecen 4032, Hungary
Full list of author information is available at the end of the article

acute neurological signs are due to stroke or to other
causes. Conditions with stroke-like symptoms but with
other etiology than stroke are called stroke mimics [2–6].
One of the conditions that may mimic stroke is acute
alcohol intoxication. Specifically, alcohol intoxication results in symptoms very similar to vertebrobasilar ischemia
[7, 8], therefore the simultaneous occurrence of vertebrobasilar stroke and alcohol intoxication may result in the
misdiagnosis of stroke. The common overlapping signs of
vertebrobasilar stroke and alcohol intoxication including
dizziness, dysarthria, nystagmus, ataxia with or without
double vision and somnolence can easily be attributed to

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Arokszallasi et al. BMC Neurology

(2019) 19:14

Page 2 of 5

the acute effects of alcohol, and the misdiagnosis may lead
to delayed stroke recognition and failure to administer
appropriate therapy [9]. Moreover, as acute alcohol intake
may be associated with inability to walk, hemispheric
symptoms may also be overlooked by lay people with poor
stroke awareness. Although there was one article which
mentioned alcohol intoxication as a stroke mimic [5], to
the best of our knowledge, no detailed description of this
topic has been published in the scientific literature. During
the past years, the acute effects of alcohol caused diagnostic challenges in some patients who presented with stroke
symptoms at our department.

Table 1 Laboratory values of the patients
Laboratory values

Case 1

Case 2

Case 3

Glucose (mmol/L)

9,2

7,2

17,6

Creatinine (μmol/L)

78

65

58

CK (U/L)

47

78

133

AST (U/L)

15

18

14

ALT (U/L)

7

14

18

GGT (U/L)

10

21

38

CRP (mg/L)

UK

3,83

4,99

Ethanol (‰)

2,3

UK

< 0,1a

Ethanol (mg/dL)

230

UK

< 10a

Case presentations

White Blood Cell (G/L)

8,58

10,21

14,74

Case 1 - A 50-year-old woman celebrated her birthday
and consumed an unknown amount of alcohol. Her
family was unable to wake her up the following morning
(7 a.m.), therefore the patient was transferred to our department (Fig. 1). On admission, somnolence, moderate
dysarthria, horizontal gaze-directed nystagmus, moderate trunk ataxia, and in-coordination were found. Her
laboratory values showed moderate alcohol intoxication
(Table 1). The symptoms were attributed to the effects of
alcohol, therefore, after a negative CT and CT-angiography,
forced diuresis was started (8:30 a.m.), and her clinical
status was checked every hour. Initially, consciousness
improved, the patient became alert, and dysarthria and
ataxia ameliorated. However, early in the afternoon (2 p.m.),

Hemoglobin (g/L)

135

150

161

Platelet (G/L)

294

277

281

INR

0,97

1

0,9

a

measured about 12 h after alcohol intake, UK unknown

the control examination revealed worsening symptoms, she
became somnolent again and developed severe horizontal
nystagmus, double vision, dysarthria and dysphagia. Due to
rapid progression, cerebral CT was repeated, which was
negative again. Similarly, duplex ultrasound showed no
stenosis of the carotid or vertebral arteries, however, transcranial Doppler (TCD) revealed high pulsatility index and
low flow velocity in the basilar artery. Due to rapid progression and the sound suspicion of basilar artery occlusion,

Fig. 1 Timeline of the 3 cases. The delay of treatment due to alcohol intoxication is indicated by diagonal lines. Bold text highlights the
symptoms which helped differentiate between stroke and alcohol intoxication. TCD: transcranial Doppler; DSA: digital subtraction angiography;
CT: computer tomography; CTA: CT angiography; MCA: middle cerebral artery

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digital subtraction angiography (DSA) was performed. DSA
showed basilar artery occlusion, therefore intraarterial
thrombolysis was performed. After the administration of
25 mg rt-PA, the basilar artery was successfully recanalised
(Fig. 2) and the symptoms rapidly improved. The control
CT 24 h after the treatment showed no abnormalities. At
discharge, the patient was symptom-free.
Case 2 - A 62-year-old man consumed about 32 g
ethanol (4 units) in the evening (Fig. 1). Before going to
bed, his wife noticed his slurred speech, and the patient
complained of double vision and trunk ataxia that was
disproportionate to the amount of alcohol he had
consumed. His wife attributed the symptoms to alcohol
consumption; however, the patient disagreed. Therefore,
paramedics were called who found mild right-sided
hemiparesis and severe dysphagia in addition to double
vision, dysarthria, and trunk ataxia. On admission to our
department, the clinical examination confirmed these
findings (NIHSS: 6 points). Cerebral CT showed no cerebral hemorrhage or infarction, therefore thrombolysis
was performed within 3 h of the onset of symptoms. The
control examination showed significant improvement,
and the NIHSS evaluated 24 h after thrombolysis decreased to 1 point.
Case 3 - A 55-year-old man consumed approximately
80 g etanol (10 units) during the night at a wedding ceremony and fell asleep at about 2 a.m. (Fig. 1). His relatives
tried to wake him up early in the morning (5 a.m.), the
patient opened his eyes, but could not speak. He seemed
to be drunk, therefore the relatives attributed the signs
to alcohol consumption and let him sleep back. Upon
awakening in the early afternoon (1 p.m.), his relatives
realized that he had facial asymmetry, mild right-sided
weakness and speech disturbance. On admission,
right-sided homonymous hemianopsia, paresis of the
lower half of right side of the face, mild right-sided
hemiparesis, and severe receptive and expressive aphasia
were found. Urgent CT scan (1:30 p.m.) revealed a huge
infarction in the left middle cerebral artery (MCA)

Page 3 of 5

territory (Fig. 3). Aspirin was administered and the risk
factors were controlled. The neurological status did not
change significantly.

Discussion and conclusions
Based on worldwide data, the average alcohol consumption in 2010 amounted to 6.2 l of pure alcohol per
person among people aged 15 years or older [10]. The
highest alcohol consumption and the highest prevalence
of heavy episodic drinking were shown in high-income
countries.
In a systematic review and meta-analysis, acute alcohol
ingestion was reported to cause an approximately
two-fold increase in stroke as early as 1 h subsequent to
alcohol consumption [11]. These results suggest that the
simultaneous occurrence of alcohol intoxication and
stroke is not a coincidence, because even moderate
alcohol consumption is associated with an immediate
increase in the risk of stroke. As the signs and symptoms
of moderate-severe alcohol intoxication resemble those
of vertebrobasilar stroke, stroke symptoms may be attributed to the effects of alcohol if the two conditions
develop simultaneously. Moreover, heavy episodic drinking may also mask the signs of hemispheric stroke for
people with poor knowledge of cerebrovascular diseases.
According to heteroanamnesis, all of our 3 patients
undoubtedly drank significant amounts of alcohol before
admission to our clinic. However, the time between alcohol consumption and blood alcohol level measurements
varied (about 6 h in the first patient, and at least 12 h in
the third patient), therefore the blood alcohol level
measured after admission did not reflect the amount of
ethanol consumed. Since the symptoms of alcohol
intoxication and stroke overlapped and in the first and
third patients the symptoms were only noticed after awakening, it was impossible to determine the precise onset of
stroke. Based on our assessment, symptoms developed
within 2 and 3 h of alcohol consumption in the second
and third patients, respectively. The onset-to-door time

Fig. 2 Case 1: Non-enhanced cranial CT showed no acute ischemic signs or hemorrhage. Digital subtraction angiography revealed basilar artery
occlusion (A) and successful recanalisation after intra-arterial thrombolysis with 25 mg rtPA

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Fig. 3 Case3: Non-enhanced cranial CT showed subacute ischemic
lesion in the area of the left middle cerebral artery

was about 2 h in the second patient, but due to the delay
in the recognition of stroke it was more than 8 h in the
third patient. In the first patient, neurological symptoms
were noticed within 5 h of alcohol consumption, however,
these symptoms were most likely to be caused by alcohol
intoxication, and obvious stroke symptoms developed
later, already in the hospital.
Our observations show that acute alcohol intoxication
may cause difficulties in differential diagnosis of stroke,
especially if ischemia develops in the vertebrobasilar territory. Our cases suggest that thorough examination and
observation are necessary to recognise stroke in the case
of simultaneous occurrence of alcohol intoxication.
Therefore, patients with alcohol intoxication require
increased attention during emergency medical care. The
first presented case underlines the importance of strict
observation after alcohol consumption. Although cerebral CT and angio-CT were negative and the patient’s
symptoms improved during forced diuresis, the cause of
initial symptoms cannot be clearly determined. They
could be due solely to alcohol intoxication or to alcohol
intoxication with concomitant vertebrobasilar stroke
with improving symptoms. Certainly, the worsening of
clinical symptoms several hours after the initial improvement could not be explained by alcohol ingestion, but
supported the diagnosis of stroke in this period of the
condition. It remains unclear whether vertebrobasilar
stroke was induced by alcohol and dehydration due to
forced diuresis, or was independent of these conditions.
This case underlines that patients with alcohol intoxication

Page 4 of 5

require increased medical attention, and emphasizes the
need for repeated controls. Certainly, if MRI is available,
diffusion-weighted imaging may help differentiate between
alcohol intoxication and stroke [12, 13].
Our second case demonstrates that symptoms disproportionate to the amount of alcohol consumed and the asymmetry of symptoms are warning signs for stroke. It must be
highlighted, however, that the patient’s relative would have
attributed the severe stroke symptoms to the effect of
small-moderate amount of alcohol. In the third case, the
patient’s status was attributed to alcohol intoxication and
therefore the stroke was not noticed in due time. The delay
in stroke diagnosis resulted in late arrival at hospital beyond
the thrombolysis time window, which eventually resulted in
an unfavourable outcome. It is well-known that thrombolytic therapy helps dissolve blood clots and restore cerebral
blood flow, and thus improves the outcome in acute ischemic stroke [14]. Based on our cases, it can be concluded
that in the case of simultanoeus occurrence of stroke and
alcohol intoxication, unusal alcohol-related clinical symptoms, such as dysphagia or hemiparesis, and disproportion
between the symptoms and the amount of alcohol
consumed may help the recognition of stroke in the
background of symptoms. One of the lessons of this report
is that in case of ambiguity, paramedics should be called
and the patient should be transferred to a stroke unit. As
patients with alcohol intoxication and stroke within the
thrombolytic time window require increased medical
attention, CT examination, angiography, and IV tPA treatment, these patients should be observed at a neurological
ICU or in a well-equipped stroke unit. If the diagnosis of
stroke cannot be excluded, diffusion-weighted MRI, if available, can be useful to determine the etiology of symptoms
[13, 15]. However, it has to be emphasized that despite
being the most sensitive technique for cerebral ischemia,
even diffusion-weighted MRI may result in a false negative
finding in stroke patients, especially in brain-stem strokes
[13, 15]. If MRI is not available or negative, but clinical
evaluation strongly suggests stroke, the worst should be assumed. In the case of dysphagia, asymmetry in symptoms
including hemiparesis, or symptoms disproportionately
severe to the amount of alcohol, ischemic stroke and rtPA
treatment should be considered. In our patients, who
arrived at the hospital in time and stroke diagnosis could
be established within the therapeutic time window, thrombolysis resulted in a significant improvement of clinical
symptoms. On the contrary, when stroke was not recognised, and therefore reperfusion therapy could not be
initiated, no improvement was achieved. As thrombolysis
in the case of stroke mimics is associated with no or only a
minimal risk of hemorrhagic complications [16, 17], rtPA
treatment can be suggested for patients with potential
ischemic stroke and simultaneous alcohol intoxication,
provided that the patient is eligible for rtPA therapy.

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Abbreviations
ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; CK: Creatine
kinase; CRP: C-reactive protein; CT: Computer tomography; DSA: Digital
subtraction angiography; GGT: Gamma-glutamyl transpeptidase;
INR: International Normalized Ratio; IV tPA: Intravenous tissue plasminogen
activator (IV tPA); MCA: Middle cerebral artery; MRI: Magnetic resonance
imaging; NIHSS: National Institutes of Health Stroke Scale; rtPA: Recombinant
tissue plasminogen activator; TCD: Transcranial Doppler
Acknowledgments
The authors wish to express their sincere thanks to the co-workers of the
Intensive Care Unit of the Department of Neurology, University of Debrecen,
and Affidea Ltd.
Funding
The study was supported by the Hungarian National Brain Research Program,
NAP_13-1-2013-0001, 2017–1.2.1-NKP-2017-00002 and by the National
Research, Development and Innovation Office, NKFH- K 120042 and K
109712. The funders had no role in study design, data collection, analysis
and interpretation of data, or preparation of the manuscript.

Page 5 of 5

3.

4.

5.

6.
7.

8.

9.
Availability of data and materials
The datasets supporting the conclusions of this case report are included
within the article.
Authors’ contributions
LO, EB and TA were involved in clinical work-up, manuscript preparation,
editing and submission. IF and KF were directly involved in the diagnosis
and treatment of the patients. IF, KF and LCs revised the manuscript critically
for important content. All authors have read and approved the final
manuscript.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Informed written consent was obtained directly from patients who were
able to fully understand and answer our questions and were oriented in
time, place and their personal data (Case 1 and 2). However, in the case of
the patient with severe expressive and receptive aphasia (Case 3), informed
written consent was given by a family member (wife).

10.

11.

12.

13.

14.

15.
Competing interests
The authors declare that they have no conflict of interest.

Publisher’s Note

16.

Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Neurology, Faculty of Medicine, University of Debrecen,
Moricz Zs. krt 22, Debrecen 4032, Hungary. 2Cerebrovascular and
Neurodegenerative Research Group of the Hungarian Academy of Sciences,
Moricz Zs. krt 22, Debrecen 4032, Hungary.
Received: 30 August 2018 Accepted: 16 January 2019

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