Teaching NeuroImages: A fuzzy determination of stroke onset

Abstract

A 73-year-old man with hypertension presented with left hemiparesis and left hemineglect of unclear duration. CT with angiography of the head and neck showed subacute infarcts of the right frontal lobe and a right internal carotid artery thrombus, with corresponding perfusion abnormalities that would have qualified him for thrombectomy (figure).1 On closer examination, his facial hair asymmetry suggested a matured hemineglect to his left face. Based on the unenhanced imaging findings and facial hair asymmetry, we estimated his stroke onset to be more than 24 hours prior to evaluation, thereby disqualifying him for thrombectomy.