• Devi Prasad Patra, Vinayak Narayan, Amey Savardekar, Rimal Hanif Dossani, Christian Cajavilca, Vijaykumar Javalkar, Eduardo Gonzalez-Toledo, and Hugo H Cuellar.
• Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
• World Neurosurg. 2018 Nov 1; 119: 1-5.

BackgroundSupratentorial stroke manifesting as ipsilateral hemiparesis is rare. Multiple pathophysiologic mechanisms are possible for this unusual phenomenon and has been previously described. Its implication in therapeutic decision making in a patient with an acute emergent condition has never been discussed. We describe our experience with a patient with this unusual presentation.Case DescriptionA 44-year-old woman presented with acute-onset right hemiparesis and left facial weakness. Evaluation with computed tomography angiography showed right M3 segment occlusion. Her National Institutes of Health Stroke Scale score on arrival was 9. Urgent magnetic resonance imaging was performed, which showed ongoing ischemia in the right frontotemporal cortex. She underwent endovascular thrombectomy, and complete revascularization was achieved. Postoperatively, the patient experience complete neurologic recovery. Further diffusion tractography imaging showed near-complete nondecussation of corticospinal fibers.ConclusionsDiscordance between clinical and initial computed tomography angiography findings in a patient with acute ischemic stroke poses a management challenge. Additional imaging to correlate clinical findings in equivocal cases may help in decision making but may significantly delay intervention, and therefore its utility during the short therapeutic window period needs careful consideration. Considering the risks and benefits, timely intervention should be balanced judiciously against appropriate intervention to achieve a positive patient outcome.Copyright © 2018 Elsevier Inc. All rights reserved.

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