What is the appropriate acute stroke workup for a 70-year-old man presenting with facial weakness?

From the Guidelines

For a 70-year-old man presenting with facial weakness suggestive of acute stroke, immediate action is crucial, and the most appropriate acute stroke workup includes a rapid neurological assessment using the NIH Stroke Scale, urgent non-contrast CT scan of the brain, and essential blood tests, as recommended by the most recent guidelines 1.

Initial Assessment

The initial assessment should include a rapid neurological examination to determine focal neurological deficits and assess stroke severity, using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) 1.

• Assessment in the acute phase should include heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 1.
• Acute blood work should be conducted as part of the initial evaluation, including electrolytes, random glucose, complete blood count, coagulation status (INR, aPTT), and creatinine 1.

Imaging and Further Evaluation

• Urgent non-contrast CT scan of the brain is recommended to rule out hemorrhage and assess for early signs of ischemia 1.
• If CT is negative for hemorrhage and symptoms are within 4.5 hours of onset, consider intravenous thrombolysis with alteplase (tPA) at a dose of 0.9 mg/kg (maximum 90 mg), with 10% given as a bolus and the remainder infused over 60 minutes.
• If time allows before tPA administration, perform CT angiography to evaluate for large vessel occlusion.
• For patients presenting between 4.5 and 24 hours, advanced imaging with CT perfusion or MRI diffusion/perfusion may identify candidates for extended-window thrombectomy.

Management and Secondary Prevention

• Admit the patient to a stroke unit for close monitoring of vital signs, neurological status, and swallowing function.
• Initiate aspirin 325 mg once CT excludes hemorrhage, unless tPA is given (in which case, delay aspirin for 24 hours).
• Begin secondary prevention measures, including high-intensity statin therapy (e.g., atorvastatin 80 mg daily), blood pressure management, and evaluation for atrial fibrillation. This approach prioritizes rapid assessment and treatment to minimize brain tissue damage, as "time is brain" in acute stroke management, and is supported by the most recent and highest quality evidence 1.

From the Research

Acute Stroke Workup for Facial Weakness

The appropriate acute stroke workup for a 70-year-old man presenting with facial weakness involves a comprehensive evaluation to determine the underlying cause of the symptoms.

• The workup may include cerebrovascular imaging to reveal new multifocal intracranial stenoses, as seen in a case report of a 70-year-old man with a history of embolic stroke, atrial fibrillation, and polymyalgia rheumatica 2.
• A detailed neurological examination is crucial to identify the type and location of the facial weakness, which can be supranuclear or peripheral 3, 4.
• Imaging studies such as magnetic resonance imaging (MRI) can help localize the lesion and provide evidence of the existence of corticofugal fibers that extend to the facial nucleus in the dorsal paramedian pontine tegmentum 3.
• The workup may also involve evaluating the patient for other conditions that can cause facial weakness, such as artery-to-artery embolism at the internal carotid bifurcation resulting in cerebral infarction mainly in the territory of the anterior cerebral artery 5.
• Additionally, video-based facial weakness analysis using a bi-directional long short-term memory network (Bi-LSTM) can be used to detect facial weakness and provide visualizable and interpretable results 6.

Key Considerations

• The evaluation approach should consider unusual stroke mechanisms in the initial evaluation of stroke codes 2.
• A thorough examination is necessary to differentiate between central and peripheral causes of facial weakness 3, 4.
• The workup should also involve assessing the patient's medical history, including conditions such as diabetes, chronic renal failure, and atrial fibrillation, which can increase the risk of stroke 2, 5.