What is the appropriate ER workup and differential diagnosis for a patient presenting with tingling on her cheek and arm?

Emergency Workup for Tingling in Cheek and Arm

The most appropriate emergency workup for a patient presenting with tingling in the cheek and arm should include urgent neuroimaging with CT or MRI of the brain to rule out acute stroke, as these symptoms strongly suggest a cerebrovascular event affecting the sensory cortex or thalamus.

Initial Assessment

Focused Neurological Examination

• Perform NIH Stroke Scale assessment 1
  • Check for facial asymmetry, arm drift, speech abnormalities
  • Assess sensory function in affected areas
  • Test motor strength in all extremities
  • Evaluate cranial nerves, particularly trigeminal (CN V) for cheek sensation
  • Check for visual field defects

Vital Signs

• Blood pressure, heart rate, respiratory rate, oxygen saturation
• Temperature (to rule out infectious causes)
• Cardiac rhythm monitoring

Differential Diagnosis

High Priority (Emergent)

1. Acute Ischemic Stroke

   • Particularly affecting the sensory cortex or thalamus
   • Tingling in contralateral face and arm is a classic presentation of cortical stroke 1

2. Transient Ischemic Attack (TIA)

   • Similar presentation to stroke but symptoms resolve within 24 hours
   • Still requires urgent evaluation as it indicates high risk for subsequent stroke

3. Intracranial Hemorrhage

   • May present with sensory symptoms before progressing to more severe deficits
   • Can cause increased intracranial pressure leading to sensory changes 1

4. Cerebral Venous Thrombosis

   • Can present with variable neurological symptoms including sensory changes
   • May have headache, seizures, or altered mental status 1

Secondary Considerations

1. Migraine with aura

   • Can cause sensory symptoms that typically spread gradually
   • Usually accompanied by headache, photophobia, or nausea

2. Multiple Sclerosis

   • Demyelinating lesions can cause sensory symptoms
   • Often accompanied by other neurological symptoms

3. Peripheral Nerve Compression

   • Less likely to explain both face and arm symptoms unless multiple sites involved 2, 3

4. Conversion Disorder/Psychogenic

   • Diagnosis of exclusion after ruling out organic causes 1

Diagnostic Workup

Immediate Imaging

• Non-contrast CT head - First-line to rule out hemorrhage 1
• CT angiography (CTA) of head and neck - To evaluate for large vessel occlusion or dissection 1
• MRI brain with diffusion-weighted imaging - If available quickly, more sensitive for acute ischemic changes

Laboratory Tests

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

Additional Studies (Based on Initial Findings)

• CT or MR perfusion - To evaluate for penumbra in acute stroke 1
• MR angiography - Alternative to CTA for vascular evaluation 1
• EKG and cardiac monitoring - To detect arrhythmias that may cause embolic events
• Carotid ultrasound - To evaluate for carotid stenosis if stroke is suspected 1

Management Considerations

Time-Critical Decision Points

• Determine last known well time
• Assess eligibility for thrombolysis (if within 4.5 hours of symptom onset) 1
• Consider mechanical thrombectomy for large vessel occlusion 1

Pitfalls to Avoid

1. Dismissing symptoms as anxiety or psychogenic without adequate workup
2. Delaying neuroimaging in a patient with sensory symptoms
3. Failing to recognize posterior circulation strokes which may present with atypical symptoms
4. Missing non-contiguous symptoms that may indicate multiple emboli

Special Considerations

• Symptoms involving both face and arm in the same distribution strongly suggest a central rather than peripheral etiology
• Tingling that follows a dermatomal or peripheral nerve distribution may indicate a different diagnosis
• The combination of facial and arm tingling is concerning for cortical sensory involvement and should be treated as a potential stroke until proven otherwise

Remember that time is critical in the evaluation of potential stroke patients, and the diagnostic workup should proceed rapidly while maintaining a high index of suspicion for cerebrovascular events.