Can stroke present with hemiplegia in the absence of facial deviation?

Stroke Can Present with Hemiplegia in the Absence of Facial Deviation

Yes, stroke can present with hemiplegia without facial deviation, as neurological deficits in stroke depend on the specific vascular territory affected and can manifest with isolated limb weakness without facial involvement. 1

Pathophysiological Basis

Stroke presentations vary based on the location and extent of brain injury:

• Different vascular territories supply different parts of the motor cortex and descending pathways
• The facial motor cortex and limb motor areas can be affected independently depending on the specific vessels involved
• Some stroke syndromes, particularly those affecting subcortical structures or the posterior circulation, may spare facial muscles while causing significant limb weakness

Clinical Recognition of Stroke Without Facial Weakness

When evaluating a patient with suspected stroke presenting with hemiplegia but no facial deviation:

• Consider stroke high on the differential diagnosis despite the absence of the complete triad of symptoms
• Remember that the FAST (Face, Arm, Speech Test) screening tool relies on three key findings, but not all need to be present 2
• Arm weakness alone shows the highest prevalence and best agreement between paramedics and physicians (96% vs 95%, kappa=0.77) compared to facial weakness (68% vs 70%, kappa=0.49) 2

Diagnostic Approach

For patients presenting with isolated hemiplegia without facial deviation:

1. Immediate brain imaging (CT or MRI) should be completed without delay 3
2. Non-invasive vascular imaging (CTA or MRA from aortic arch to vertex) should be performed urgently 3, 1
3. Complete ECG without delay to identify potential cardioembolic sources 3, 1

Special Stroke Syndromes to Consider

Several specific stroke syndromes can present with hemiplegia without facial involvement:

• Pure motor hemiparesis: A lacunar syndrome affecting the posterior limb of the internal capsule
• Weber's syndrome: A midbrain stroke that can present with contralateral hemiparesis and ipsilateral oculomotor nerve palsy rather than typical facial weakness 4
• Posterior circulation strokes: May present with hemiplegia but spare facial muscles due to their different vascular supply

Clinical Implications and Pitfalls

• Don't exclude stroke based on absence of facial weakness: The presence of acute arm drift alone significantly increases the likelihood of stroke (LR of ≥1 finding = 5.5; 95% CI, 3.3-9.1) 5
• Risk stratification remains high: Patients with isolated unilateral limb weakness are still considered at highest risk for stroke and require immediate evaluation 3, 1
• Diagnostic accuracy: While the classic triad of facial weakness, arm drift, and speech disturbance has the highest sensitivity for stroke, the absence of facial weakness does not rule out stroke when other neurological deficits are present 5

Management Considerations

For patients with suspected stroke presenting with hemiplegia without facial deviation:

• Immediate referral: Send to an emergency department with advanced stroke care capabilities 3, 1
• Urgent imaging: Complete brain and vascular imaging within 24 hours 3
• Time-sensitive treatment: Consider thrombolysis and/or thrombectomy if within appropriate time windows
• Secondary prevention: Initiate appropriate antiplatelet therapy, statins, and blood pressure management 1

Remember that the absence of facial weakness should not delay stroke evaluation and management, as isolated hemiplegia remains a high-risk presentation requiring urgent assessment and treatment.