A localization conundrum

Every respectable textbook mentions this, but it is still a wonder to see it (as we did last Saturday).

A 52 yo female is brought in by the Notarzt (EMS doc) with dense hemiplegia on the right. It seems that the patient just managed to call the EMS, before she collapsed; the Notarzt found her with paralysis of the right arm and leg, progressing to dense hemiplegia over the 20 minutes it took to reach the ER. Now the patient is restless, throws her head back and forth, right and left, crying that she is in pain, her arm is hurting and her leg is. She does not respond to any question, is in grave distress. After an opiate she becomes somnolent and whispers that the problem started 10 mins before she called the EMS (about 40 mins ago now) and then stops, obviously at peace with the world.

On examination she is somnolent, GCS 10 with intact cranial nerves. Her right arm is MRC 0, as is her right leg. She is also analgesic on the right arm and leg, though not on the trunk. The face is intact. On the left she has some degree of weakness at her leg, but develops enough strength to turn in her bed. The reflexes are pretty much down on the right, normal at the left arm, brisk at the left lower extremity, with some ankle clonus and Babinski’s on the left.

This is it. You can make a diagnosis out of that. There is no differential. Any ideas?

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