HPI. 76-year-old right-handed woman, hypertension, diabetes, atrial fibrillation on warfarin (sub-therapeutic, INR 1.6). Baseline mRS 1 — lives independently, drives, still volunteers. Family last saw her well last night around 10 PM. This morning around 6 AM the visiting daughter found her on the floor, not responsie, with right-sided weakness. EMS arrived; ED arrival 1 PM.

Last known well: yesterday 10 PM. Time since LKW: 15 hours.

Exam. Awake, global aphasia. Left gaze preference, dense global aphasia, right facial droop, dense right arm and leg plegia (0/5). NIHSS 18.

Imaging.

• Non-contrast CT: established hypodensity across the left M1, M2, M4, M5 territories — ASPECTS 3. (See axial NCCT below.)
• CTA: left proximal M1 occlusion. Patent right ICA, no tandem cervical lesion.

Labs. INR 1.2, platelets 245k, glucose 158.

HPI. 62-year-old right-handed woman, history of hypertension and diabetes. Family reports she started to have problems with her speech Tuesday around 6 PM. Wednesday at noon she was unable to get any words out and had right-sided arm and face weakness, so EMS was called.

Last known well: Tuesday 6 PM. Time since onset: 18 hours.

Exam. Severe expressive aphasia, right facial droop, right arm weakness (3/5), mild right leg weakness (4/5). NIHSS 8.

Imaging.

• Non-contrast CT: Normal, ASPECTS 10.
• CTA: left M3 (anterior superior division) occlusion. No tandem cervical disease.
• CT perfusion: 2 mL core / 16 mL penumbra / mismatch ratio 8.

Labs. INR 1.1, platelets 220k, glucose 124.