A 77 year old right handed man presented with a history of resolving right sided weakness. His right arm and leg were affected, and his arm felt “heavier” than his leg. His wife noticed that his face drooped on the right side and that he used the “wrong words” when speaking. Within an hour of admission his weakness completely resolved, and a transient ischaemic attack was diagnosed.

Forty eight hours after presentation, the patient re-presented to the accident and emergency department. He was reviewed by a trainee doctor (foundation year 2). He had a dense right sided hemiparesis, his right arm was worse than his right leg, and he had “forehead sparing” facial weakness. He was dysphasic, with his gaze preference to the left. His pulse was regular at 90 beats a minute and his blood pressure was 140/90 mm Hg. He had no clinical signs of meningism. His symptoms had been present for 30 minutes and had not improved.