Case description

A right-handed man in his 40s presented to a local hospital after 2 days of progressively worsening episodes of aphasia. He had hypertension and prior nicotine dependence. He was not eligible for acute stroke therapies owing to his delayed presentation. MR scan of the brain showed left frontal and parietal infarcts (figure 1). Subsequent CT angiogram of the head and neck showed an extensive intraluminal thrombus involving the extracranial left internal carotid artery with an associated non-stenotic plaque (figure 2A–D). Haemoglobin A1c was elevated at 7.1%, indicating a new diagnosis of diabetes. Laboratory studies, including lipid and coagulation profiles, were unrevealing. Transthoracic echocardiogram was normal. He was started on low-dose aspirin and heparin infusion (later changed to apixaban for anticoagulation) and statin therapy. There were no further neurological episodes. One month later, he was assessed in our cerebrovascular clinic. Neurological examination identified …