What is the workup for a brief episode of unilateral hemiplegia?

Workup for Brief Episode of Unilateral Hemiplegia

A brief episode of unilateral hemiplegia requires immediate referral to an emergency department with advanced stroke care capabilities for urgent brain and vascular imaging within 24 hours, as this presentation is considered very high risk for stroke recurrence. 1

Risk Stratification

Very High Risk (Symptom onset within 48 hours)

• Transient, fluctuating, or persistent unilateral weakness (face, arm, and/or leg) is considered highest risk for stroke recurrence 1
• These patients should be immediately sent to an emergency department with capacity for advanced stroke care 1

Immediate Diagnostic Workup

1. Brain Imaging

   • Urgent brain CT or MRI should be completed without delay 1
   • MRI with diffusion-weighted imaging is preferred when available as it has greater diagnostic ability for acute infarction 2, 3

2. Vascular Imaging

   • Non-invasive vascular imaging from aortic arch to vertex should be completed urgently 1
   • CT angiography (CTA) of both extracranial and intracranial circulation should be performed at the time of initial brain CT 1
   • Alternatives include MR angiography (MRA) or carotid ultrasound if CTA is not available 1

3. Cardiac Assessment

   • Electrocardiogram (ECG) should be completed without delay 1
   • Consider prolonged cardiac monitoring and echocardiography if vascular etiology is not identified 3

4. Laboratory Investigations

   • Complete blood count with platelet count
   • Coagulation studies (aPTT, INR)
   • Electrolytes and renal function
   • Blood glucose levels
   • Lipid profile 1, 4

Management Algorithm

1. If symptoms occurred within last 48 hours:

   • Immediate transfer to emergency department with stroke care capabilities
   • Complete brain imaging (CT/MRI) and vascular imaging (CTA/MRA) within 24 hours
   • ECG and basic laboratory tests without delay
   • Consider admission for observation, especially if ABCD² score ≥3 4, 3

2. If symptoms occurred between 48 hours and 2 weeks ago:

   • Comprehensive clinical evaluation by healthcare professional with stroke expertise within 24 hours
   • Complete brain and vascular imaging within 24 hours
   • ECG and laboratory tests as soon as possible 1

3. If symptoms occurred more than 2 weeks ago:

   • Evaluation by neurologist or stroke specialist within one month
   • Complete brain and vascular imaging as part of evaluation 1

Treatment Considerations

• Antiplatelet therapy should be initiated within 24 hours if no contraindications exist 4
• High-intensity statin therapy should be initiated regardless of baseline cholesterol levels 4
• Antihypertensive therapy should be started within 24 hours after stroke, targeting blood pressure <140/90 mmHg 4
• For patients with atrial fibrillation, consider long-term oral anticoagulation 4
• For significant carotid stenosis (>50%), consider carotid revascularization, with greatest benefit when performed within 2 weeks of symptom onset 4

Important Caveats

• Brief episodes of hemiplegia are often TIAs but can represent other conditions such as Todd's paralysis, hemiplegic migraine, or infectious processes 5
• Risk of stroke is highest in the first week following TIA, with an 8.8% risk at 7 days 4
• Reliance on risk stratification instruments alone is not recommended for discharge decisions from the ED 2
• The absence of findings on initial non-contrast head CT does not rule out ischemia, as early infarcts may not be visible 2
• Consider rapid diagnostic protocols or observation units to reduce length of stay while ensuring appropriate evaluation 2