A fifty-three year old legal secretary suddenly complained of dizziness and suboccipital headache. She subsequently experienced nausea and her vision was “blurred”. She attempted to walk from her desk to the bathroom but was unsteady and lurched from side to side. Co-workers noted that her speech was slightly slurred. Thirty minutes later the patient was found lying on the bathroom floor, arousable but mentally confused. She was unable to stand or walk without assistance. She was subsequently brought to the Emergency Room. Her initial examination occurred one hour after her first symptoms. Patient was moderately obese and blood pressure was 150/100 in both arms. Pulse was 80 and regular. She was now stuporous but could be aroused by noxious stimuli. She made purposeful movements with her right hand, but moved her left poorly. When grimacing, in response to noxious stimuli, she had symmetrical facial movements bilaterally. The patient had full range of motion in both eyes with no nystagmus. The patient’s neck was somewhat stiff to passive movements. Pupils were 3 mm in diameter and reacted briskly to light bilaterally. The funduscopic examination demonstrated small hemorrhages indicative of diabetes. Reflexes were hypoactive bilaterally in arms and legs, and the plantar response was extensor on the left, and flexor on the right. Family history was noncontributory. The patient had a history of diabetes for the past five years requiring daily insulin injections, and smoked a pack of cigarettes a day for the past twenty years. A routine blood pressure, six months prior to the present illness, had been 140/90. The patient took no other medication.

 A blood sugar was 215 mg/dl. Complete blood count and serum electrolytes were normal. A lumbar puncture performed 1½ hours after the ictus revealed bloody spinal fluid that did not clear in three different tubes. Centrifugation of the bloody CSF resulted in a pellet of cells with a crystal clear supernatant.

 That evening, six hours after her initial symptoms, the patient was in a deep coma unresponsive to noxious stimuli. The pupils were pinpoint and reactive. She had lost all oculo-vestibular reflexes and her eyes did not move laterally in response to passive lateral rotation of the head and neck. Corneal responses were intact bilaterally. She had lost voluntary withdrawal responses on the right side, and the plantar response was extensor bilaterally. A CT scan was performed.