Dont neglect the clock drawing test

Introduction

A 63-year-old, right-handed woman with a history of hypertension presented to the ED with left arm paresis of 2 days duration. Three weeks before admission, she had flu-like symptoms with intermittent left arm weakness that had recovered briefly but recurred 2 days prior to her presentation. On neurological examination, GCS was 15 and cranial nerves' function was normal. Left upper limb strength was 4/5. There was left arm drift and pronation but the patient denied noticing any difference between the positions of her arms. Hyper-reflexion was presented in the left arm. The rest of her motor, cerebellar, sensation and gait functions were normal. She was asked to draw a clock and set it to 15:30 (figure 1).

Figure 1

Clock drawing test results.

Question:

What is the most probable aetiology?

Right cerebral bleeding involving the occipital lobe

Right middle cerebral artery occlusion

Right parietal lesion, likely neoplasm

Left cortical stroke

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