Acute Onset Hemiparesis

65-year-old male presenting with sudden onset right-sided weakness and aphasia. Last seen well 2 hours ago. Past medical history includes hypertension and atrial fibrillation.

Clinical Presentation

A 65-year-old male with a history of hypertension and atrial fibrillation presents to the emergency department with sudden onset right-sided weakness and aphasia. His last known well time was 2 hours prior to presentation.

On examination, the patient has right facial droop, right arm drift (4/5 strength), and expressive aphasia. NIHSS score is 14.

Non-contrast CT head shows hyperdense left MCA sign with early loss of insular ribbon. No evidence of hemorrhage.

CT perfusion demonstrates a large penumbra with small core mismatch, indicating favorable tissue for intervention.

The patient underwent mechanical thrombectomy with TICI 3 recanalization. Post-procedure NIHSS improved to 6.

Follow-up imaging at 24 hours shows no hemorrhagic transformation. The patient was started on antiplatelet therapy and discharged to rehabilitation on day 5.

Key Imaging Findings

• Hyperdense MCA sign on non-contrast CT
• Loss of insular ribbon
• Large penumbra with small core on CT perfusion
• Complete recanalization post-thrombectomy

Discussion

This case demonstrates the importance of rapid stroke assessment and the role of advanced imaging in selecting patients for mechanical thrombectomy. The patient's atrial fibrillation likely contributed to an embolic stroke mechanism.