A 59-year-old man with a history of hypertension presents to the emergency department (ED) with right-sided paralysis and aphasia. The patient’s wife states he was in his normal state of health until 1 hour ago, when she heard a thud in the bathroom and walked in to find him collapsed on the floor. She immediately called emergency medical services, which transported the patient to your ED. En route, his fingerstick blood sugar was 108 mg/dL. On arrival in the ED, the patient is placed on monitors and an IV is established. His temperature is 36.8°C (98.2°F), blood pressure is 169/93 mm Hg, heart rate is 86 beats per minute, and respiratory rate is 20 breaths per minute. The patient has a noticeable left-gaze preference and is verbally unresponsive, although he will follow simple commands such as raising his left thumb. He has a normal neurologic examination on the left, but on the right he has a facial droop, no motor activity, decreased deep tendon reflexes (DTRs), and no sensation to light-touch.
What is the most likely diagnosis?
What is the most appropriate next step?
What is the best therapy?
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