What is the management for a patient presenting with right hemiplegia and facial droop due to a stroke?

Management of Right Hemiplegia and Facial Droop Due to Stroke

Patients presenting with right hemiplegia and facial droop due to stroke require immediate emergency medical services activation, rapid transport to a stroke-capable center, and time-critical interventions to minimize brain damage and improve outcomes.

Initial Emergency Response

Prehospital Management

• Immediate EMS activation is strongly recommended when stroke symptoms are recognized 1
• EMS personnel should use validated stroke assessment tools including FAST (Face, Arm, Speech, Time) 1
• On-scene time should be minimized to a median of 20 minutes or less 1
• Critical prehospital actions:
  • Obtain information about symptom onset time/last known well time
  • Assess vital signs and perform capillary blood glucose measurement
  • Pre-notify receiving hospital of incoming stroke patient 1, 2
  • Direct transport to appropriate stroke-capable facility 1

Emergency Department Evaluation

• Immediate clinical evaluation for airway, breathing, and circulation 1
• Rapid neurological examination using standardized stroke scale (NIHSS) 1, 3
• Urgent brain imaging (CT or MRI) within 24 hours, ideally immediately 1, 3
• Assessment of heart rate/rhythm, blood pressure, temperature, oxygen saturation, hydration status 1
• Initial blood work including glucose, complete blood count, coagulation studies 1

Acute Treatment

Thrombolytic Therapy

• Intravenous alteplase (tPA) should be administered at 0.9 mg/kg (maximum 90 mg) with 10% as bolus and 90% as infusion over 60 minutes 3
• Target door-to-needle time of <60 minutes in 90% of patients (median 30 minutes) 3
• Time window for standard IV thrombolysis is within 4.5 hours of symptom onset 1, 3
• Blood pressure management:
  • For patients eligible for thrombolysis: maintain BP <185/110 mmHg 3
  • For patients ineligible for thrombolysis: only treat if BP >220/120 mmHg 3

Endovascular Therapy

• Consider endovascular treatment for patients with large vessel occlusion 3, 4
• May be beneficial even beyond 6 hours in selected patients 4

Antiplatelet Therapy

• Initiate aspirin (325 mg initially, then 81-325 mg daily) within 24-48 hours if no contraindications and no thrombolysis 3

Management of Complications

Cerebral Edema

• For large hemispheric infarctions with significant swelling:
  • Decompressive craniectomy with dural expansion for patients <60 years old who deteriorate neurologically 3
  • Initial medical management: mild fluid restriction, head elevation by 20-30 degrees 3
  • Monitor for signs of increased intracranial pressure 3

Prevention of Secondary Complications

• Deep vein thrombosis prophylaxis for immobilized patients 3
• Monitor for and promptly treat pneumonia, especially in immobile patients 3
• Avoid indwelling bladder catheters when possible 3

Early Rehabilitation

• Initiate rehabilitation within 24-48 hours if patient is stable 3
• Multidisciplinary team approach with regular meetings 3
• Cognitive assessment and retraining for attention deficits, visual neglect, memory deficits 3

Prognosis Discussion

• For patients <60 years old with decompressive craniectomy, nearly 3 of 4 patients survive, but nearly half will be severely disabled 3
• Care by a multidisciplinary team in a stroke unit improves functional outcome and reduces mortality regardless of age, sex, initial severity, and type of stroke 3

Common Pitfalls to Avoid

• Delaying EMS activation or transport for additional outpatient evaluation 1
• Failing to determine and document the exact time of symptom onset/last known well 1
• Inadequate blood pressure management before and after thrombolysis 3
• Overlooking the need for early rehabilitation and secondary prevention 3

By following this structured approach to the management of right hemiplegia and facial droop due to stroke, healthcare providers can optimize patient outcomes through rapid assessment, time-critical interventions, and comprehensive care.