Intended for healthcare professionals

Endgames Spot Diagnosis

An unusual cause of stroke

BMJ 2022; 379 doi: (Published 01 December 2022) Cite this as: BMJ 2022;379:e066326
  1. Jacob Day, neurology registrar,
  2. Daniel Lashley, consultant neurologist
  1. University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, UK
  1. Correspondence to: J Day jacobday{at}

A woman in her 60s presented with acute onset numbness and weakness of the left arm and leg for three days on a background of fatigue and weight loss without headache over six months. She took ramipril for hypertension but was normally well. She was admitted under the care of the acute stroke team, and magnetic resonance imaging of the brain confirmed right middle cerebral artery territory infarction. Initial investigations also revealed biochemical evidence of inflammation (table 1). Neither atrial fibrillation nor carotid artery stenosis (on Doppler ultrasound) were identified as causes for her stroke.

View this table:
Table 1

Results of initial investigation of patient

Empirical treatment for infective endocarditis was initiated, given the combination of lethargy, …

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