A 58-Year-Old Right-Handed Man Is Brought to the Emergency Department

A 58-year-old right-handed man is brought to the emergency department with sudden onset of severe difficulty speaking and weakness that developed over a few seconds while he was at work.  His other medical problems include hypertension, hyperlipidemia, severe left atrial enlargement (seen on previous echocardiogram) , mild bilateral carotid disease with recent carotid ultrasound showing <30% stenosis, type 2 diabetes mellitus, and autosomal dominant polycystic kidney disease.  He is not compliant with his medication regimen.  The patient smokes a pack of cigarettes a day and drinks alcohol occasionally.  His blood pressure is 156/96 mm Hg and pulse is 124/min and irregularly irregular.  His body mass index is 35 kg/m².  There are no carotid bruits.  The patient speaks in very short sentences and has difficulty finding words while trying to speak.  He is awake and alert but has difficulty following simple commands.  There is a forced conjugate gaze preference to the left, neglect of the right visual field, and severe right lower facial droop.  He has marked weakness and sensory loss in the right arm and mild weakness and sensory loss in the right leg.  His fingerstick glucose value is 345 mg/dL.  Which of the following is the most likely cause of this patient's current condition?

A) Cardiogenic emboli
B) Carotid artery atherosclerosis
C) Hyperglycemic nonketotic state
D) Subarachnoid hemorrhage
E) Subcortical lacunar stroke

Correct Answer:

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