What is the initial workup for a patient presenting with right-sided paralysis?

Initial Workup for Right-Sided Paralysis

The initial workup for a patient presenting with right-sided paralysis should include urgent neuroimaging with CT or MRI of the brain to rule out acute ischemic stroke, as this is the most common cause requiring immediate intervention. 1

Immediate Assessment

History

• Onset and timing (sudden vs. gradual)
• Associated symptoms (speech difficulties, visual changes, headache, dizziness)
• Risk factors for stroke (hypertension, diabetes, smoking, atrial fibrillation)
• Recent trauma or surgery
• Recent illness or infection
• Medication use

Physical Examination

• Vital signs (particularly blood pressure)
• Complete neurological examination using the National Institutes of Health Stroke Scale (NIHSS) 1
  • Level of consciousness
  • Language function
  • Visual fields
  • Facial movement
  • Motor function in arms and legs
  • Sensory testing
  • Coordination
  • Presence of neglect or inattention

Diagnostic Testing

Immediate Testing

1. Neuroimaging:

   • Non-contrast CT scan of the brain (to rule out hemorrhage)
   • CT angiography or MRI/MRA if ischemic stroke is suspected
   • MRI is more sensitive for early detection of ischemic changes

2. Laboratory Studies:

   • Complete blood count
   • Comprehensive metabolic panel
   • Coagulation studies (PT/INR, PTT)
   • Blood glucose
   • Cardiac enzymes

Secondary Testing (Based on Initial Findings)

• Electrocardiogram (ECG)
• Carotid ultrasound
• Echocardiogram (if cardioembolic source suspected)
• Electroencephalogram (if seizure activity suspected)

Differential Diagnosis

1. Acute Ischemic Stroke - Most common cause requiring immediate intervention

   • Time is critical - treatment with IV tPA must be given within 4.5 hours of symptom onset 1

2. Intracranial Hemorrhage

   • Requires different management than ischemic stroke
   • Contraindication to thrombolytic therapy

3. Bell's Palsy - If paralysis is limited to the face 1

   • Assess for other neurological deficits to distinguish from stroke
   • Look for complete facial involvement (forehead and lower face)

4. Todd's Paralysis - Post-ictal state following seizure

   • Temporary weakness that resolves within 24-48 hours

5. Hemiplegic Migraine

   • Typically with headache and visual symptoms
   • Temporary neurological deficits

6. Mass Lesion (tumor, abscess)

   • Often more gradual onset
   • May have other symptoms like headache, seizures

Management Algorithm

1. If acute stroke is suspected (sudden onset, <4.5 hours):

   • Activate stroke protocol
   • Secure airway, breathing, circulation
   • Obtain immediate neuroimaging
   • Assess eligibility for IV thrombolysis or endovascular intervention
   • Blood pressure management (target <185/110 mmHg if thrombolysis is planned) 1

2. If Bell's palsy is suspected (isolated facial weakness):

   • Prescribe oral steroids within 72 hours of symptom onset 1
   • Implement eye protection measures for impaired eye closure 1
   • Consider antiviral therapy in addition to steroids 1

3. If other causes are suspected:

   • Tailor additional testing based on clinical presentation
   • Consider neurology consultation

Common Pitfalls and Caveats

1. Mistaking Bell's palsy for stroke

   • Bell's palsy affects the entire side of the face including forehead
   • Stroke typically spares forehead due to bilateral innervation

2. Delayed recognition of stroke

   • Remember "Time is Brain" - each minute delay results in loss of approximately 1.9 million neurons
   • Don't wait for all test results if clinical suspicion is high

3. Overlooking posterior circulation strokes

   • May present with atypical symptoms
   • Consider MRI if CT is negative but clinical suspicion remains high

4. Failing to recognize mimics

   • Hypoglycemia, seizures, and migraines can all mimic stroke symptoms
   • Check glucose early in evaluation

5. Inadequate follow-up

   • For Bell's palsy, reassess or refer to specialist if:
     • New/worsening neurological findings
     • Ocular symptoms develop
     • Incomplete recovery after 3 months 1

Right-sided paralysis requires prompt evaluation and management to minimize morbidity and mortality. The initial workup should focus on rapidly determining whether the patient is experiencing an acute stroke requiring immediate intervention or another condition with different management requirements.