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Young patient with aphasia, monoparesis, facial drop, facial sensory loss, diplopia, dysarthria, and vertical gaze palsy.

We present a case of a 40-year-old male without previous medical history and medication who denied tobacco smoking or alcohol abuse. He led a healthy lifestyle, and there were no cardiovascular risk factors in his family history. In October 2012, he experienced acute onset of horizontal diplopia while playing with his child. During the transport to the emergency room, he developed a left-sided facial drop and dysarthria. On arrival, he was immediately moved to the computed tomography (CT) room as a candidate for intravenous thrombolysis and was examined by a stroke neurologist. At that time, the patient’s level of consciousness was slightly drowsy, but he was orientated. His pupils were equal with normal reactions to light. He had horizontal diplopia in either direction, more pronounced on the right side. The right eye was nasally deviated. There was no problem with vertical eye movements. He had facial sensory loss on the left side, left-sided facial drop causing dysarthria, and difficulty with word finding. There were no sensorimotor findings in the upper extremities. He was able to raise his right lower extremity, but could not hold it in the upright position for 5 seconds, and the Babinski sign was present on the right side. The National Institutes of Health Stroke Score was 6.

With the suspicion of posterior circulation stroke, a noncontrast computed tomographic head scan and CT angiography were ordered. There was no pathology on noncontrast computed tomographic scan. Before CT angiography findings were available, the patient’s symptoms progressed. He became mute but understood verbal commands and developed a vertical gaze palsy. There was confusion …