28th May 2025

An 89-year-old man is brought into A&E from a nursing home with new left facial droop and left-sided weakness.

An 89-year-old man is brought into A&E from a nursing home with new left facial droop and left-sided weakness.

His carer is with him. The patient has a history of previous stroke on the left and has residual right-sided weakness. The carer also describes that the patient is slow when he moves, has an unstable, wide-based gait, and can be unsteady on his feet, causing multiple previous falls. He is incontinent of urine, and the carer reports he requires a thickened fluid diet due to issues with his swallowing.

On neurological examination, he has reduced tone, facial droop and weakness and significant drift on the left. In addition, you also find hypertonia, a contracture of the right upper limb, a severe right-sided weakness, rigidity in both legs, and brisk reflexes.

The CT head shows a right acute infarct, a left established infarct, small vessel disease and multiple lacunar infarcts. Ventricle sizes are in keeping with age.

Other than the acute right-sided infarct, what is the most likely underlying diagnosis contributing to his problems with mobility?