A mechanic with confusion and right-sided weakness

A 47-year-old man presented as a thrombolysis call. A family member had visited that morning, finding him confused with difficulty speaking and dragging his right leg and arm. There had been difficulty finding words for several days. He had been seen at his local general practice twice in the preceding 4 months for daily headaches. He was a non-smoker with no known vascular risk factors, and took no regular medication. He lived alone and worked as a mechanic. A long-term relationship with a female partner had ended 6 months previously.

On examination, he was dysarthric and disorientated in space and time. His right arm and leg were weak proximally (MRC grade 4). There was patchy alopecia of his scalp and beard.

Initial MR brain imaging showed multifocal T2 hyperintensity with restricted diffusion in the left frontal/insular cortex and left internal capsule (figure 1A,B) consistent with acute infarcts. Cerebrospinal fluid (CSF)…

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