A 65 year old male with a past medical history of poorly controlled hypertension presents with new onset unilateral arm and leg weakness. There is no disturbance of consciousness and there is no evidence of cortical findings (such as aphasia, agnosia, or hemianopia). What is the most likely location of the vascular obstruction

In locating the puncture site, a line connecting the posterior superior iliac crests will intersect the midline at approximately L4.

Explanation:

Lacunar infarcts occur at the small, terminal branches of the vasculature and more commonly occur in African-Americans and patients with diabetes and hypertension. This patient's presentation, evidenced by pure loss of motor function without disturbances in other neurological modalities, is consistent with an infarct in the internal capsule. Because terminal branches of the vasculature supply the internal capsule, it is frequently affected in patients with diabetes and hypertension. A vascular obstruction in the MCA would affect not only motor functions, but also produce cortical findings such as aphasia or agnosia.

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