6/5/25, 18:25 29-Year-Old Man With Sudden-Onset Aphasia and Left-Arm Weakness
Medscape > Case Challenges
29-Year-Old Man With Sudden-Onset
Aphasia and Left-Arm Weakness
Omar Islam, MD; Zara A. Khan, BHSc; Donatella Tampieri, MD
DISCLOSURES | April 17, 2025
Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of
which are not frequently encountered by most clinicians, but are nonetheless
important to accurately recognize. Test your diagnostic and treatment skills
using the following patient scenario and corresponding questions. If you have
a case that you would like to suggest for a future Case Challenge, please email
us at with the subject line "Case Challenge
Suggestion." We look forward to hearing from you.
Background and Presentation
A 29-year-old man presents to the emergency department with sudden-onset
aphasia and left-arm weakness. The patient’s initial appearance is that of a
healthy, well-developed male. He says he has not had any fevers, chills, cough,
or nausea.
He has no history of prior medical conditions, takes no prescription drugs, and
has no history of smoking or illicit drug use. He has no remarkable social
history, such as lifestyle behaviors, personal habits, or environmental factors
that may influence his health, including occupation, social support, and living
conditions. He works in construction as a heavy-equipment operator.
Which test would be most important to order for this patient?
CT of the head (noncontrast)
CT of the head with CT angiography of the neck and head
Carotid Doppler ultrasonography
https://reference.medscape.com/viewarticle/29-year-old-man-sudden-onset-aphasia-and-left-arm-weakness-2025a100091o#vp_6 1/13
, 6/5/25, 18:25 29-Year-Old Man With Sudden-Onset Aphasia and Left-Arm Weakness
Electroencephalography
SAVE AND PROCEED
Which test would be most important to order for this patient?
Your Peers Chose:
CT of the head (noncontrast) 26%
CT of the head with CT angiography of the neck and head 68%
Carotid Doppler ultrasonography 4%
Electroencephalography 2%
CT of the head is required to exclude an acute cortical infarction or
hemorrhage. Given the patient’s presentation with stroke-like symptoms,
analysis of the major vessels in the neck (carotid and vertebral arteries) and
the circle of Willis with CT angiography is important to exclude a vascular
cause such as dissection, thromboembolic disease, or large-/medium-vessel
vasculitis.
A noncontrast head CT alone would not be sufficient to analyze the blood
vessels.
Carotid Doppler ultrasonography would not be indicated in this patient
presenting with acute stroke-like symptoms, unless the patient has a
contraindication for CT angiography, in which case magnetic resonance
angiography would be a viable alternative.
Electroencephalography is not indicated in the initial assessment of acute
neurologic symptoms, although it may show diffuse slowing over the affected
hemisphere.
Physical Examination and Workup
https://reference.medscape.com/viewarticle/29-year-old-man-sudden-onset-aphasia-and-left-arm-weakness-2025a100091o#vp_6 2/13
Medscape > Case Challenges
29-Year-Old Man With Sudden-Onset
Aphasia and Left-Arm Weakness
Omar Islam, MD; Zara A. Khan, BHSc; Donatella Tampieri, MD
DISCLOSURES | April 17, 2025
Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of
which are not frequently encountered by most clinicians, but are nonetheless
important to accurately recognize. Test your diagnostic and treatment skills
using the following patient scenario and corresponding questions. If you have
a case that you would like to suggest for a future Case Challenge, please email
us at with the subject line "Case Challenge
Suggestion." We look forward to hearing from you.
Background and Presentation
A 29-year-old man presents to the emergency department with sudden-onset
aphasia and left-arm weakness. The patient’s initial appearance is that of a
healthy, well-developed male. He says he has not had any fevers, chills, cough,
or nausea.
He has no history of prior medical conditions, takes no prescription drugs, and
has no history of smoking or illicit drug use. He has no remarkable social
history, such as lifestyle behaviors, personal habits, or environmental factors
that may influence his health, including occupation, social support, and living
conditions. He works in construction as a heavy-equipment operator.
Which test would be most important to order for this patient?
CT of the head (noncontrast)
CT of the head with CT angiography of the neck and head
Carotid Doppler ultrasonography
https://reference.medscape.com/viewarticle/29-year-old-man-sudden-onset-aphasia-and-left-arm-weakness-2025a100091o#vp_6 1/13
, 6/5/25, 18:25 29-Year-Old Man With Sudden-Onset Aphasia and Left-Arm Weakness
Electroencephalography
SAVE AND PROCEED
Which test would be most important to order for this patient?
Your Peers Chose:
CT of the head (noncontrast) 26%
CT of the head with CT angiography of the neck and head 68%
Carotid Doppler ultrasonography 4%
Electroencephalography 2%
CT of the head is required to exclude an acute cortical infarction or
hemorrhage. Given the patient’s presentation with stroke-like symptoms,
analysis of the major vessels in the neck (carotid and vertebral arteries) and
the circle of Willis with CT angiography is important to exclude a vascular
cause such as dissection, thromboembolic disease, or large-/medium-vessel
vasculitis.
A noncontrast head CT alone would not be sufficient to analyze the blood
vessels.
Carotid Doppler ultrasonography would not be indicated in this patient
presenting with acute stroke-like symptoms, unless the patient has a
contraindication for CT angiography, in which case magnetic resonance
angiography would be a viable alternative.
Electroencephalography is not indicated in the initial assessment of acute
neurologic symptoms, although it may show diffuse slowing over the affected
hemisphere.
Physical Examination and Workup
https://reference.medscape.com/viewarticle/29-year-old-man-sudden-onset-aphasia-and-left-arm-weakness-2025a100091o#vp_6 2/13
