Acute aphasia. What is the likely etiology?

A 60-something man without significant past history presented after sudden onset of aphasia 45 minutes prior.  There was also a report of a few days of abdominal pain, nausea and vomiting, and of not being himself.BP was 165/80, pulse 110.  He had profound expressive aphasia but his motor exam was intact.A stroke code was called and the patient underwent a CT stroke series.  Non-contrast scan showed no bleed and no evidence of infarct.  Cerebral CT angiography did not show a large vessel occlusion.He was rapidly given tPA (alteplase).An ECG was obtained (ECG-1):What does it show?  Is this relevant to the stroke?A previous was available from 6 years prior that was normal:ECG-1: There is a QS-wave in V2, with ST Elevation and some T-wave inversion.  There is a tiny r-wave in V3, also with STE and TWI.  There is STE in V4 and V5, with some T-wave inversion.  Is this LV aneurysm?  Or acute MI?  Or subacute MI?If there is a single lead in V1-V4 which has a T/QRS ratio ＞ 0.36, then there is likely acute MI.  If the ratio is ＜0.36, it is likely old (LV aneurysm) or subacute; symptoms of ＞6 hours duration suggest subacute, and ＜6 hours as acute.  The ratio in lead V2 is 3.5/5.0 = 0.70, so this is an acute anterior MI.  The QS-wave suggests that it is nearly complete.  It could also be an old MI with superimposed acute LAD occlusion.This is diagnostic of Anterior MI, acute or subacute, butnot simpl...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs