Timeline	Events
Initial presentation	Sudden onset of unresponsiveness and right upper and lower extremity and right lower facial weakness Computed tomography of the head shows hyperdensity of left sylvian branch of the middle cerebral artery (MCA) (M2) region. Computed tomography angiogram was consistent with left M2 occlusion. He was given tissue plasminogen activator (tPA) and taken to interventional neuroradiology for thrombectomy. Admitted to neuro-intensive care unit.
Day 1	Started on Aspirin and Statin. Transthoracic echocardiogram showing left ventricular ejection fraction of 35% and microbubbles seen in the left atrium (LA), left ventricle, and coronary sinus (CS) with agitated saline study.
Day 2	Admit to step down unit. Physical therapy evaluation.
Day 3	Magnetic resonance imaging of brain showing acute to early subacute left MCA territory infarct. No haemorrhagic transformation. Additional acute to early subacute punctate infarct in the right occipital lobe. Chronic left cerebellar infarcts.
Day 4	Gated cardiac CT confirmed a wide communication between tde CS and LA consistent witd unroofed CS.
Day 4	Gated cardiac CT with CT coronary angiography demonstrated extensive coronary plaque in the left main (LM), proximal to mid left anterior descending (LAD) >70% stenosis, and the proximal to mid right coronary artery (50–69% stenosis). Lower extremity ultrasounds negative for deep vein thrombosis.
Day 5	Invasive coronary angiography shows 50% distal LM lesion and chronic total occlusion of the mid-LAD. Unremarkable right heart catheterization. Cardiac surgery recommends follow-up evaluation after 6 weeks. Patient discharged to an acute rehabilitation facility.