A 63-year old man, with a past medical history of hypertension and dyslipidemia, presented with a one-day history of isolated left-hand weakness of sudden onset. Neurological examination revealed a left ‘wrist-drop’ and weak extension of the digits. Sensation was intact. Brain magnetic resonance imaging (MRI) showed a typical ‘omega’ shaped area of restricted diffusion in the ‘motor hand strip’ over the M1 ‘knob area’ (A). There was the presence of a large homogeneous plaque with surface ulceration on cervical duplex sonography of the right internal carotid artery (B) and microembolic signals were observed on transcranial Doppler (C).