The patient, a 67-year-old female, was brought to the emergency department for acutely altered mental status. Her medical history included diabetes, hypertension, and hyperlipidemia. The daughter reported confusion and speech difficulties during a phone call, prompting EMS intervention. 

EMS found the patient displaying aggressive and uncooperative behavior without focal neurological deficits. The situation escalated when she barricaded herself in a bathroom, leading to law enforcement involvement. Midazolam was administered to facilitate hospital transport due to concern for stroke as a cause of her agitation and presumed lack of capacity to refuse treatment. 

Initial evaluation in the emergency department was limited by sedation, but no focal deficits were noted. Code Brain was activated with the stroke team’s assessment revealing word-finding difficulties and dysarthria. A non-contrast CT showed early ischemic changes in the left temporal lobe, and CT angiography confirmed occlusion of the left ICA.

The misdiagnosis rate for acute stroke in emergency medicine ranges from 2% to 26%, with atypical presentations often being overlooked. Ischemic strokes in the right MCA or posterior circulation often present with acute behavioral changes, making this case atypical since the patient experienced a left-sided stroke.

This case highlights the diagnostic challenges and ethical considerations in atypical stroke presentations and emphasizes the need for a high index of suspicion for cerebrovascular events in patients exhibiting sudden behavioral changes.