On arrival, she complained of acute onset left upper extremity weakness. A stroke alert was initiated. The patient’s systolic blood pressure was 180 mmHg and the ECG demonstrated atrial fibrillation at 90 beats per minute. On neurologic examination, the left upper extremity strength revealed no effort against gravity with some preserved strength in wrist and finger extension. Diminished sensation to gross touch on the left forearm compared to the right. Findings from the remainder of the neurological examination, including speech and language, cranial nerves, coordination, and left lower extremity strength and sensation, were normal. A computed tomography scan of the brain showed no gross evidence of intracranial hemorrhage. There was hypodensity representing age-indeterminate infarct within the left occipital lobe and age-indeterminate periventricular and subcortical small vessel ischemic changes.