A 63-year-old right-handed man, retired construction worker, and part-time professional musician with history of hypertension and hyperlipidemia presented to his local hospital with sudden onset of right-sided weakness and language difficulties. He was treated with intravenous tPA.

Our patient had a sudden onset of right-sided weakness and language difficulties. At the local emergency room, his blood pressure was 230/120 mm Hg. He received intravenous labetalol, and after a computed tomography (CT) scan was obtained and blood pressure parameters became within appropriate range for thrombolytic therapy, intravenous tPA was administered. His right-sided hemiparesis improved, but his language impairment persisted.

Additional ancillary investigations showed an elevated antinuclear antibody (ANA) (1:2,560) nucleolar pattern, elevated cholesterol, low-density lipoprotein (LDL), and triglycerides. Echocardiography showed left ventricular hypertrophy and aortic valve sclerosis, but no evidence of intracardiac thrombi or right-to-left shunt. Carotid ultrasound showed mild plaque formation of both carotid artery bulbs. Magnetic resonance imaging (MRI) showed a large middle cerebral artery territory infarction. Magnetic resonance angiography (MRA) showed decreased visualization of a few branches of the inferior division of the left middle cerebral artery. He received antiplatelet therapy, antihypertensives, and a statin. He was referred for further evaluation.