A 65-year-old man is brought to the emergency department due to left arm weakness and slurred speech, which he first noticed on waking this morning. He is accompanied by his wife, who says that his symptoms improved markedly 2 hours after they appeared but then significantly worsened again an hour ago. The patient has a history of coronary artery disease, hypertension, type 2 diabetes mellitus, and hyperlipidemia. A bare metal stent was placed in his left circumflex artery 7 years ago. The patient also has chronic kidney disease with an estimated glomerular filtration rate of 60 mL/min/1.73 m². Medications include aspirin, metformin, carvedilol, and lisinopril. The patient has a 40-pack-year history. His mother had polycystic kidney disease, and his father died of a heart attack.
Blood pressure is 175/105 mm Hg and pulse is 65/min and regular. On neurologic examination, the patient is awake and alert. He has a left homonymous hemianopia, right forced gaze deviation, reduced sensation on the left side of the face, and left lower facial paresis. He also has left-sided hemiplegia with an extensor plantar response.
Which of the following is most likely responsible for this patient's current condition?

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11ec193a_9657_168e_853d_0387e460c3bb_MD0002_00 This patient's focal neurologic deficits are consistent with a right middle cerebral artery (MCA) stroke. MCA strokes typically present with contralateral somatosensory and motor weakness (eg, face, arm, leg). Patients can also have conjugate eye deviation toward the side of the infarct, contralateral homonymous hemianopia (superior and inferior optic radiations), hemineglect (nondominant hemisphere), and/or aphasia (dominant hemisphere). Causes of ischemic stroke can often be differentiated by the following clinical characteristics and progression of symptoms: Causes Thrombotic strokes are due to local (in situ) obstruction of large arteries, usually in areas of underlying atherosclerosis. Patients typically have atherosclerotic risk factors (eg, hypertension) and develop fluctuating symptoms with periodic improvement (ie, stuttering progression).Embolic strokes are often due to a thrombus arising remotely in the heart, aorta, or large vessels (eg, atrial fibrillation, paradoxic embolism across the patent foramen ovale). Therefore, embolic strokes usually involve an abrupt onset of focal neurologic findings with maximal symptoms at onset. Patients may have an embolic obstruction of multiple vascular territories, either synchronously (ie, embolic shower) or metachronously (Choice B). Thrombotic strokes are due to local (in situ) obstruction of large arteries, usually in areas of underlying atherosclerosis. Patients typically have atherosclerotic risk factors (eg, hypertension) and develop fluctuating symptoms with periodic improvement (ie, stuttering progression). Thrombotic strokes are due to local (in situ) obstruction of large arteries, usually in areas of underlying atherosclerosis. Patients typically have atherosclerotic risk factors (eg, hypertension) and develop fluctuating symptoms with periodic improvement (ie, stuttering progression). Embolic strokes are often due to a thrombus arising remotely in the heart, aorta, or large vessels (eg, atrial fibrillation, paradoxic embolism across the patent foramen ovale). Therefore, embolic strokes usually involve an abrupt onset of focal neurologic findings with maximal symptoms at onset. Patients may have an embolic obstruction of multiple vascular territories, either synchronously (ie, embolic shower) or metachronously (Choice B). Embolic strokes are often due to a thrombus arising remotely in the heart, aorta, or large vessels (eg, atrial fibrillation, paradoxic embolism across the patent foramen ovale). Therefore, embolic strokes usually involve an abrupt onset of focal neurologic findings with maximal symptoms at onset. Patients may have an embolic obstruction of multiple vascular territories, either synchronously (ie, embolic shower) or metachronously (Choice B). This patient's fluctuating, progressive neurologic deficits indicate a thrombotic ischemic stroke of the MCA. (Choice C) Small-vessel lipohyalinosis typically causes lacunar infarcts due to the occlusion of a single penetrating branch of a larger artery. Patients usually develop limited focal motor and/or sensory symptoms without cortical signs. This patient's extensive neurologic deficits, including hemiparesis, hemianesthesia, and cortical signs (eg, homonymous hemianopia, gaze preference) make a large cortical infarct more likely. lacunar infarcts (Choice D) Spontaneous subarachnoid hemorrhage is usually due to a ruptured arterial saccular (berry) aneurysm and presents with sudden-onset headache associated with possible meningismus or focal neurologic deficits. This patient's intermittent symptoms without headache or rapid progression of symptoms make hemorrhagic stroke less likely. (Choice E) Acute subdural hematomas form after rupture of a bridging vein, typically due to trauma. They can rarely present with focal deficits, but global deficits (eg disturbance of consciousness) are more typical. In addition, gradual progression (vs fluctuation) of symptoms, typically over 24-48 hours, is more common. Educational objective: Ischemic strokes may be caused by embolism or thrombosis. Embolic strokes usually have an abrupt onset of focal neurologic findings with maximal symptoms at onset. Thrombotic strokes usually present as fluctuating symptoms with periodic improvement and a stuttering progression. __________ References: Assessment of the predictive validity of etiologic stroke classification. (http://www.ncbi.nlm.nih.gov/pubmed/28241214) The underlying stroke etiology: a comparison of two classifications in a rural setup. (http://www.ncbi.nlm.nih.gov/pubmed/31341751) TOAST criteria applied in acute ischemic stroke. (http://www.ncbi.nlm.nih.gov/pubmed/16146496)

A 65-Year-Old Man Is Brought to the Emergency Department Due