From the Guidelines
Yes, it is consistent to have right facial droop and left-sided weakness, as this pattern typically indicates a stroke affecting the right side of the brain, specifically in the motor cortex or its pathways. The brain's motor control system is organized in a crossed manner, where the left hemisphere controls the right side of the body and the right hemisphere controls the left side. However, facial nerve innervation is more complex. The upper face receives bilateral innervation from both hemispheres, while the lower face receives contralateral innervation (from the opposite hemisphere) 1.
In a right-sided brain lesion, the patient would experience weakness on the left side of the body (arm and leg) and drooping of the right side of the face, particularly the lower face. This pattern is a classic presentation of a hemispheric stroke and represents an important localizing sign in neurological examination. According to the 2018 Canadian Stroke Best Practice Recommendations, patients who present with transient, fluctuating, or persistent unilateral weakness (face, arm, and/or leg) are considered at highest risk of first or recurrent stroke 1.
Some key points to consider in patients with these symptoms include:
- Urgent brain imaging (computed tomography (CT) or magnetic resonance imaging (MRI)) and non-invasive vascular imaging (CT angiography (CTA) or MR angiography (MRA) from aortic arch to vertex) should be completed as soon as possible within 24 h 1
- An electrocardiogram (ECG) should be completed without delay 1
- Immediate medical attention should be sought if these symptoms occur suddenly, as they may indicate an acute stroke requiring emergency treatment.
From the Research
Clinical Presentation
- The combination of right facial droop and left-sided weakness can be consistent with a stroke, as it suggests a lesion in the right brain hemisphere that affects the facial nucleus and the motor pathways to the left side of the body 2, 3.
- However, it is essential to consider other potential causes of these symptoms, such as Miller Fisher syndrome, which can present with facial droop, dysphagia, and weakness, mimicking a stroke 4.
Diagnostic Approach
- Advanced imaging techniques, such as MRI or CT perfusion, can help guide the diagnosis and treatment of acute stroke, including identifying patients who may benefit from thrombolysis or mechanical thrombectomy 2, 3.
- The use of MRI-based selection protocols for thrombolysis has been shown to be safe and effective, even in patients with minor deficits or unknown time of symptom onset 3, 5.
Treatment Options
- Intravenous thrombolysis with alteplase or tenecteplase can be an effective treatment for acute ischemic stroke, especially when initiated within a few hours of symptom onset 2, 6.
- Mechanical thrombectomy may also be considered for patients with large vessel occlusion, even if the time of symptom onset is unknown or beyond the traditional time window for thrombolysis 2, 6.