A 71 year old man with right sided facial droop

A 71 year old man noticed a right sided facial droop while shaving in the morning. When a neighbour visited shortly afterwards he had difficulty expressing himself. She called for an ambulance and he was taken to the accident and emergency department.

He had a history of amputation above the right knee for peripheral vascular disease, emphysema, and myocardial infarction.

His drugs included ramipril, simvastatin, and omeprazole. He was an ex-smoker of 50 pack years and drank alcohol occasionally. He lived alone and was independent in a wheelchair.

His blood pressure was 116/76 mm Hg and his pulse regular at 74 beats/min. His chest was clear and heart sounds normal. Neurological examination showed dysarthria with both an expressive and mild receptive dysphasia. He had right sided facial weakness with sparing of the forehead. Limb muscle tone was normal; muscle power was 3/5 grading in the right upper limb and normal in the left upper limb, left lower limb, and right stump.

Chest radiography showed cardiomegaly and electrocardiography (ECG) showed sinus rhythm, with poor R wave progression and widespread Twave inversion in leads V4-6 and leads II, III, and avF. Urgent computed tomography of the head showed a left middle cerebral artery infarct. He was given thrombolytic treatment within three hours of the onset of his symptoms. In view of the substantial changes on ECG, urgent echocardiography was performed the day after admission (fig 1⇓).