When Clinical Judgment Goes Beyond Balance, Eyes, Face, Arm, Speech (BEFAST): Acute Confusion Prompting Stroke Code Activation in Dominant Hemisphere Large Vessel Occlusion.

Acute ischemic stroke can present with atypical features, including confusion, disorientation, or other cortical manifestations that may not be captured by commonly used stroke recognition tools such as Balance, Eyes, Face, Arm, Speech (BEFAST), posing a diagnostic challenge in the emergency department and potentially delaying identification of large vessel occlusion (LVO) and reperfusion therapy. We report a 46-year-old previously independent male who presented with acute-onset confusion following a syncopal episode that was preceded by headache and dizziness. Initial BEFAST assessment was unremarkable with preserved motor function, but a stroke code was activated due to acute cognitive change. Neuroimaging demonstrated early ischemic changes in the left cerebral hemisphere with complete occlusion of the terminal segment of the left internal carotid artery (ICA). The patient was not eligible for intravenous thrombolysis and subsequently underwent successful mechanical thrombectomy with complete reperfusion. His clinical course was notable for persistent aphasia with preserved motor strength, later re-occlusion of the ICA managed conservatively, and gradual improvement with supportive care and speech therapy. This case highlights acute confusion as a potential presenting feature of ischemic stroke due to LVO and emphasizes that reliance solely on initial rapid stroke screening tools may miss patients with predominantly cortical involvement, underscoring the importance of early clinical judgment-driven stroke activation and prompt neuroimaging in atypical presentations.