What is the next step in management for a 77-year-old male patient with a history of facial weakness, now asymptomatic with normal orthostatic blood pressure (BP) and no signs of stroke?

From the Guidelines

The next step in management for this 77-year-old male with resolved facial weakness should be a comprehensive neurological evaluation including brain imaging, preferably an MRI with diffusion-weighted imaging, as recommended by the most recent guidelines 1. This patient requires prompt assessment for a possible transient ischemic attack (TIA) or minor stroke, even though he is currently asymptomatic. I recommend scheduling these tests within 24-48 hours, along with carotid ultrasound, ECG, and basic laboratory tests including complete blood count, metabolic panel, lipid profile, and HbA1c. While awaiting these results, the patient should be started on antiplatelet therapy, typically aspirin 81-325 mg daily, unless contraindicated, as suggested by the guidelines for patients with ischemic stroke or TIA 1. If atrial fibrillation is detected, anticoagulation with a direct oral anticoagulant (such as apixaban 5 mg twice daily) would be indicated instead. This urgent workup is necessary because facial weakness, even if resolved, may represent a TIA which significantly increases the risk of subsequent stroke, as highlighted in the clinical practice guideline for Bell's palsy 1. The normal orthostatic blood pressure is reassuring but does not rule out cerebrovascular pathology. Early intervention with appropriate secondary prevention measures can substantially reduce the risk of a disabling stroke in this elderly patient with a concerning neurological symptom. It is also important to consider other potential causes of facial paralysis, such as tumors, infections, or inflammatory diseases, and to evaluate the patient's history and physical examination to detect any signs of these conditions, as outlined in the ACR Appropriateness Criteria for cranial neuropathy 1. However, given the patient's age and presentation, a vascular cause is a significant concern, and the guidelines for stroke management should be followed 1.

From the Research

Management of Facial Weakness

The patient's history of facial weakness, now asymptomatic with normal orthostatic blood pressure and no signs of stroke, suggests a possible diagnosis of Bell's palsy.

• The patient's age and lack of symptoms on this visit are consistent with a favorable outcome, as stated in the study 2.
• However, the presence of risk factors such as hypertension, diabetes mellitus, and hypercholesterolemia may affect the prognosis of Bell's palsy, as shown in studies 3, 4, and 5.
• The study 2 concludes that corticosteroids are highly likely to increase the probability of recovery of facial weakness and should be offered, while the addition of an antiviral to steroids may increase the likelihood of recovery but only by a modest effect.

Monitoring and Follow-up

Given the patient's current asymptomatic status and normal orthostatic blood pressure, the decision to continue monitoring for any signs or symptoms and schedule a follow-up appointment in three months is reasonable.

• The study 2 suggests that even without treatment, the outcome of Bell's palsy is favorable, but treatment with corticosteroids significantly increases the likelihood of improvement.
• The patient's neurological assessment being within normal limits (WNL) is a good sign, but continued monitoring is necessary to detect any potential recurrence or development of new symptoms.

Consideration of Comorbidities

The patient's medical history should be reviewed to identify any potential comorbidities that may affect the prognosis of Bell's palsy, such as diabetes mellitus, hypertension, or hypercholesterolemia.

• Studies 4 and 5 highlight the importance of considering these comorbidities in the management of Bell's palsy, as they may impact the patient's outcome and response to treatment.