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A woman in her mid-70s presented to the emergency department with a 2-day history of right-hand clumsiness. Her medical history included well-controlled diabetes, hypertension and dyslipidaemia. She was taking manidipine and rosuvastatin. On presentation, she was alert and oriented. Vital signs included a blood pressure of 145/74 mm Hg and a heart rate of 66 beats per minute. Cardiac auscultation revealed no murmurs, and peripheral pulses were symmetric. A brief neurological examination revealed an excavated appearance of the right palm during the pronator drift test, although neither pronation nor drift of the right arm was observed ( figure 1A). Extraocular movements and facial strength were normal, and no dysarthria was present. The Mingazzini test was unremarkable. The emergency physician initially suspected a stroke, but a head MRI ruled out this possibility.