From the Guidelines
The best next step for this 73-year-old man with facial weakness is option B: Computed tomography of the head and computed tomography angiography of the head and neck. This approach is appropriate because the patient presents with acute facial weakness and risk factors for stroke including hypertension, type 2 diabetes mellitus, and hyperlipidemia. CT head is the initial imaging modality of choice in suspected stroke as it can quickly rule out hemorrhagic stroke and major ischemic changes. CT angiography allows visualization of the cerebral vasculature to identify potential large vessel occlusions or stenosis that might be amenable to intervention. The most recent and highest quality study, 1, supports the use of neuroimaging in patients with suspected stroke, particularly in those with vascular risk factors. While MRI provides better soft tissue detail for identifying small or posterior circulation infarcts, CT is faster and more readily available in emergency settings. The isolated facial weakness without other neurological deficits could represent either a small stroke or Bell's palsy, but given the patient's multiple vascular risk factors, stroke must be ruled out promptly. Key points to consider in the management of this patient include:
- The importance of quickly ruling out hemorrhagic stroke and major ischemic changes
- The role of CT angiography in identifying potential large vessel occlusions or stenosis
- The need to consider alternative diagnoses, such as Bell's palsy, but to prioritize stroke given the patient's risk factors
- The value of the most recent study, 1, in guiding the management of patients with suspected stroke.
From the Research
Diagnostic Approach
The patient presents with facial weakness, which is a common symptom of stroke. Given the patient's history of hypertension, type 2 diabetes mellitus, and hyperlipidemia, it is essential to determine the cause of the stroke.
- The patient's symptoms and medical history suggest a possible ischemic stroke, which requires immediate imaging to determine the extent of the infarct and to identify any potential causes, such as arterial occlusion or cardioembolic sources 2.
- Computed Tomography (CT) of the head and CT angiography of the head and neck are commonly used imaging modalities in the acute setting of stroke to exclude hemorrhage, identify stroke mimics, and determine the cause and mechanism of stroke 3, 4, 2.
- Magnetic Resonance Imaging (MRI) of the brain and magnetic resonance angiography of the head and neck can also be used, but CT is often preferred in the emergency setting due to its rapid acquisition time and availability 2.
Best Next Step
Based on the evidence, the best next step would be to perform:
- B. Computed Tomography of the head and computed tomography angiography of the head and neck: This will allow for rapid evaluation of the patient's symptoms, exclusion of hemorrhage, and identification of potential causes of the stroke, such as arterial occlusion or cardioembolic sources 3, 4, 2.
Additional Considerations
- Echocardiography may be considered later in the diagnostic work-up to evaluate for cardioembolic sources of stroke, but it is not the best next step in the acute setting 5.
- No further testing is not a suitable option at this point, as imaging is essential to determine the cause and extent of the stroke 2.