1. Andrew Levin, PGY3 Ronald Hamilton, MD

2. 64 y/o woman with a hx of HTN, DM1 and ESRD transferred urgently to PUH ED from local vascular outpatient surgery center Per EMS: under twilight anesthesia, she suddenly stiffened on the table. There is also a report that she had some lip-smacking Reportedly stopped answering questions Possible weakness on her right side.

3. Minimal improvement in mentation w/ Narcan Surgery terminated abruptly and sent urgently to PUH (surgical sheath still embedded in fistula)

5. Arrives to ED at 3:40pm NEURO: MS: Drowsy but arousable. Answers all questions with "ok" or "mmhmm" CN: PERRL. Does not follow commands to assess cranial nerves. MOTOR: Decreased bulk. Normal tone. Able to only lift left arm, which is antigravity. Left arm has a pronator drift. Unable to lift right arm or bilateral lower extremities off the bed. REFLEXES: No ankle clonus SENSORY: Unable to assess sensory fully. Does withdraw from pain. COORDINATION: Unable to assess coordinateion GAIT: deferred.

6. 1A. Level of Consciousness (0-3) = 1 1B. LOC Questions (0-2) = 2 1C. LOC Commands (0-2) = 2 2. Best Horizontal Gaze (0-2) = 1 3. Visual Fields (0-3) = 1 4. Facial Palsy (0-3) = 1 5. Motor Arm Right (0-4) = 4 Left (0-4) = 3 6. Motor Leg Right (0-4) = 4 Left (0-4) = 4

8. CTH: No acute process CTA: Occlusion of superior and inferior M2 CTP: Relatively matched defect pLMCA territory What else would you do? What’s the mechanism? Not given tPA or sent to IA Admitted to NICU vascular surgery and renal medicine consulted

9. MRI following morning (next slide)

11. MRI following morning: Acute L pMCA infarct, small infarcts: L occipital, b/l cerebellar Innumerable microhemorrhages c/w amyloid angiopathy Vascular surgery removed retained surgical sheath Seen by renal medicine and underwent dialysis over night for K+ 8.6 NIHSS improved to 18 (from 27) on HD2 Sister, working with PL and palliative, changed code status from DNR/DNI to CMO on HD3 Passed away on HD4

12. Gross Pathology prediction Histology Prediction