What is the first step in managing a patient with sudden onset weakness and paralysis of one side of the body?

Management of Acute Hemiplegia with Facial Nerve Paralysis

The first step in managing a patient with sudden onset left-sided hemiplegia and facial nerve paralysis should be an urgent head CT scan (option C).

Clinical Presentation Analysis

The patient presents with:

• Weakness in the left half of the body
• Facial nerve paralysis on clinical examination
• Hemiplegia

This clinical presentation strongly suggests an acute stroke, specifically affecting the right cerebral hemisphere. The combination of facial weakness and hemiplegia on the same side indicates a central nervous system lesion rather than a peripheral nerve problem.

Diagnostic Approach

Immediate Imaging

• Head CT is the first-line imaging study in suspected stroke 1, 2
• CT can rapidly differentiate between:
  • Ischemic stroke
  • Hemorrhagic stroke
  • Other intracranial pathologies (mass, abscess)

The American Heart Association/American Stroke Association guidelines emphasize that immediate neuroimaging with non-contrast CT is essential to rule out hemorrhage before considering any treatment options 1.

Why CT Before Medications?

1. Treatment decisions depend on stroke type: Hemorrhagic strokes require different management than ischemic strokes
2. Time-sensitive interventions: Early identification allows for timely interventions
3. Contraindications: Certain treatments (like thrombolytics) are contraindicated in hemorrhagic stroke

Why Not Other Options?

Aspirin (Option A)

• While aspirin is beneficial in ischemic stroke, it should not be administered before determining stroke type
• Aspirin is contraindicated in hemorrhagic stroke and could worsen bleeding 1
• The American Heart Association recommends aspirin (160-325 mg) only after hemorrhage is ruled out by imaging 1

Clopidogrel (Option B)

• Not indicated for initial management of acute stroke
• Used primarily for long-term secondary prevention 1
• Should not be administered before determining stroke type

MRI (Option D)

• While MRI provides excellent detail, it takes longer to perform than CT
• Not as readily available in emergency settings
• CT is faster and sufficient for initial assessment in acute stroke 2

Comprehensive Management Algorithm

1. Initial Assessment (first minutes):

   • Secure airway, breathing, circulation
   • Rapid neurological assessment using standardized scales (NIHSS)

2. Immediate Head CT (within minutes of arrival):

   • Non-contrast CT to differentiate between ischemic and hemorrhagic stroke

3. Additional Urgent Studies (after CT):

   • CT angiography if large vessel occlusion is suspected
   • ECG to assess for cardiac causes
   • Basic laboratory tests including glucose, coagulation parameters

4. Treatment Based on CT Results:

   • If ischemic stroke and within time window: Consider IV thrombolysis
   • If hemorrhagic stroke: Blood pressure management, reversal of anticoagulation if applicable
   • If large vessel occlusion: Evaluate for endovascular therapy

Time Considerations

The "time is brain" concept is critical in stroke management:

• For every minute delay in stroke treatment, an estimated 1.9 million neurons are lost 2
• CT should be performed within minutes of arrival
• Door-to-needle time for thrombolysis should be less than 60 minutes

Conclusion

Head CT (option C) is definitively the first step in managing a patient with sudden onset left-sided hemiplegia and facial nerve paralysis. This approach aligns with current stroke management guidelines and allows for appropriate triage and treatment decisions based on the type of stroke identified.