Is a patient with transient dizziness, nasolabial (nasolabial fold) droop on the left side, but normal cheek puffing and communication, concerning for a potential stroke or Transient Ischemic Attack (TIA)?

Urgent Evaluation Needed for Patient with Dizziness and Nasolabial Droop

A patient with transient dizziness lasting 15 seconds and left-sided nasolabial droop, even with normal cheek puffing and communication, requires immediate evaluation in an emergency department with advanced stroke care capabilities as this presentation is highly concerning for a transient ischemic attack (TIA) or stroke. 1

Risk Assessment

The patient's presentation includes:

• Transient dizziness (15 seconds)
• Facial asymmetry (nasolabial droop on left side)
• Preserved ability to puff cheeks
• Intact communication

This combination of symptoms is concerning for several reasons:

• According to Canadian Stroke Best Practice Guidelines, patients with transient, fluctuating, or persistent unilateral weakness (including facial weakness) within 48 hours are considered at highest risk of recurrent stroke 1
• The nasolabial droop represents a focal neurological deficit, which is associated with a nearly 6-fold increased risk of serious neurologic diagnosis 2
• Even brief symptoms (15 seconds) can indicate TIA, which carries a high risk of subsequent stroke - up to 8.6% within 7 days and 12% within 30 days of symptom onset 3

Diagnostic Algorithm

1. Immediate ED referral: The patient should be immediately sent to an emergency department with capacity for advanced stroke care 1

2. Urgent imaging:

   • Brain imaging (CT or MRI) without delay
   • Noninvasive vascular imaging (CTA or MRA from arch to vertex)
   • ECG without delay 1, 4

3. Additional testing:

   • Complete blood count
   • Blood glucose
   • Coagulation studies
   • Electrolytes and renal function tests 4

4. Risk stratification:

   • Apply ABCD2 score to assess stroke risk:
     • Age ≥60 years (1 point)
     • Blood pressure ≥140/90 mmHg (1 point)
     • Clinical features: unilateral weakness (2 points), speech disturbance without weakness (1 point)
     • Duration: <10 minutes (0 points), 10-59 minutes (1 point), ≥60 minutes (2 points)
     • Diabetes (1 point) 4

Clinical Reasoning

While the patient's ability to communicate well and puff cheeks normally might seem reassuring, the presence of a nasolabial droop represents a focal neurological deficit that cannot be dismissed. The brief duration of dizziness (15 seconds) does not rule out a TIA - in fact, TIAs are typically defined as lasting less than 24 hours, with a usual duration of less than 15 minutes 4.

The differential diagnosis includes:

• Transient ischemic attack
• Ischemic stroke
• Benign paroxysmal positional vertigo (BPPV)
• Vestibular neuritis
• Migraine-associated vertigo

However, BPPV and vestibular neuritis typically do not present with facial asymmetry 1. The presence of a nasolabial droop significantly raises concern for a cerebrovascular event.

Common Pitfalls to Avoid

1. Dismissing brief symptoms: Even very brief symptoms can indicate TIA with high risk of subsequent stroke 3

2. Focusing only on dizziness: Dizziness alone is often benign, but when accompanied by focal neurological findings like facial asymmetry, it significantly increases the likelihood of serious pathology 2

3. Overreliance on preserved function: Normal cheek puffing and communication are reassuring but do not rule out TIA or stroke, as different facial nerve pathways may be affected differently 1, 4

4. Delayed evaluation: The risk of stroke after TIA is highest in the first 48 hours, making immediate evaluation crucial 1, 3

5. Inadequate imaging: Both brain and vascular imaging are necessary to properly evaluate this patient 1, 4

In conclusion, while some aspects of this presentation might seem reassuring, the combination of dizziness with a facial asymmetry warrants immediate evaluation to rule out TIA or stroke and prevent potentially devastating consequences.