What is the next best step in managing a 73-year-old man with hypertension (High Blood Pressure), type 2 diabetes mellitus, and hyperlipidemia (Elevated Lipid Levels) presenting with facial weakness concerning for stroke?

Next Best Step in Managing a 73-Year-Old with Facial Weakness Concerning for Stroke

The next best step in this case is to perform a CT of the head and CT angiography of the head and neck. 1

Clinical Assessment and Risk Stratification

This 73-year-old man presents with:

• Facial weakness concerning for stroke
• Multiple vascular risk factors (hypertension, type 2 diabetes mellitus, hyperlipidemia)
• Normal cranial nerve testing except for right-sided upper and lower face weakness
• Normal motor strength without pronator drift
• Normal sensory examination
• Hypoactive reflexes without Babinski sign

The presentation is concerning for a possible stroke, and the patient's age and risk factors place him at high risk for cerebrovascular disease.

Imaging Selection Rationale

1. CT Head with CT Angiography (CTA) of Head and Neck

   • This is the preferred initial imaging modality for suspected acute stroke 1
   • Canadian Stroke Best Practice Guidelines specifically recommend CT and CTA from aortic arch to vertex as soon as possible within 24 hours for patients with suspected stroke 1
   • CTA allows assessment of both extracranial and intracranial circulation in one examination 1
   • Helps identify large vessel occlusions, stenosis, or other vascular abnormalities that may require urgent intervention

2. Why Not MRI/MRA First?

   • While MRI provides superior tissue characterization, CT is more readily available, faster, and sufficient for initial evaluation 1
   • CT can quickly rule out hemorrhage, which is essential before considering any antithrombotic therapy
   • MRI can be considered as a follow-up study if the CT is negative but clinical suspicion remains high

3. Why Not Echocardiography First?

   • Echocardiography is important but should follow initial brain and vascular imaging
   • It's part of the secondary workup to identify cardiac sources of embolism 1

4. Why Not "No Further Testing"?

   • Given the patient's presentation with focal neurological deficit (facial weakness) and multiple vascular risk factors, stroke must be ruled out
   • Facial weakness could represent a stroke in the distribution of the facial nerve nucleus or its supranuclear pathways

Management Algorithm

1. Immediate Imaging

   • CT head without contrast to rule out hemorrhage
   • CTA of head and neck from aortic arch to vertex 1

2. Additional Initial Workup

   • ECG should be completed without delay 1
   • Basic laboratory tests: CBC, electrolytes, coagulation studies, renal function, glucose 1

3. After Initial Imaging

   • If ischemic stroke is confirmed and within appropriate time window, consider thrombolysis and/or endovascular therapy
   • If no acute findings but clinical suspicion remains high, consider MRI brain
   • Initiate appropriate antithrombotic therapy if hemorrhage is ruled out 1

4. Secondary Prevention Workup

   • Echocardiography to evaluate for cardiac sources of embolism
   • Lipid panel and HbA1c to assess risk factor control
   • Consider additional testing based on initial findings

Common Pitfalls to Avoid

• Delaying Imaging: Time is brain - prompt imaging is essential for treatment decisions
• Assuming Bell's Palsy: Facial weakness can be peripheral (Bell's palsy) or central (stroke); the involvement of both upper and lower face suggests peripheral involvement, but stroke must be ruled out given the patient's risk factors
• Incomplete Vascular Assessment: Evaluating only intracranial vessels may miss extracranial carotid or vertebral disease that could be the source of symptoms
• Neglecting Risk Factor Management: Regardless of imaging findings, aggressive management of hypertension, diabetes, and hyperlipidemia is essential for secondary prevention 1

In conclusion, CT head with CTA of head and neck represents the most appropriate next step in the evaluation of this patient with facial weakness and multiple vascular risk factors.