What therapy is indicated for an elderly patient with weakness in the right hand, mild weakness with right wrist extension, and normal CT scan and x-ray results?

Wrist Splint for Radial Nerve Compression

This patient requires a wrist splint for radial nerve compression (Saturday night palsy), not stroke treatment. The clinical presentation—isolated right wrist extensor weakness after sleeping in an awkward position, normal brain CT, preserved cranial nerve function, and baseline dementia without acute change—is pathognomonic for compressive radial neuropathy, not cerebrovascular disease 1.

Clinical Reasoning

Why This Is NOT a Stroke

• Isolated peripheral nerve distribution: The weakness is confined to wrist extension (radial nerve territory), not a cortical or subcortical vascular distribution 2
• Mechanical etiology: Direct compression from awkward sleep position is the clear precipitating event 1
• Normal brain imaging: CT scan excludes intracranial pathology 1
• Preserved cranial nerves: Stroke affecting hand motor function would typically involve facial weakness or other cortical signs 2
• Baseline dementia unchanged: No acute alteration in mental status beyond baseline 1

Appropriate Management

Wrist splinting in neutral or slight extension is the definitive treatment for radial nerve palsy to prevent wrist drop contracture and allow nerve recovery 1. The splint maintains functional hand position while the compressed nerve segment recovers over weeks to months.

Why Other Options Are Incorrect

Antiplatelet Agents (Option A)

Antiplatelet therapy is indicated for TIA or minor stroke to prevent recurrence, with dual antiplatelet therapy (aspirin plus clopidogrel) reducing 3-month stroke risk from 7.8% to 5.2% 2. However, this patient has no evidence of cerebrovascular ischemia—the normal CT, isolated peripheral nerve pattern, and mechanical etiology exclude TIA 2, 3.

Thrombectomy (Option B)

Mechanical thrombectomy is reserved for disabling acute ischemic stroke with large-vessel occlusion, improving functional independence from 26.5% to 46.0% when performed within 6 hours 2. This patient has neither disabling deficits nor vascular occlusion—the weakness is mild, peripheral in distribution, and imaging shows no intracranial pathology 1, 2.

Thrombolysis (Option C)

IV alteplase is indicated for disabling stroke within 4.5 hours, improving outcomes when deficits interfere with activities of daily living 2. This patient has no indication for thrombolysis: the weakness is non-disabling, follows a peripheral nerve pattern, brain imaging is normal, and the mechanism is compressive rather than ischemic 1, 2.

Common Pitfalls to Avoid

• Over-diagnosing stroke in elderly patients: Not every neurologic deficit in an elderly patient represents cerebrovascular disease, especially with clear mechanical precipitants 1
• Ignoring anatomic localization: Isolated wrist extensor weakness without cortical signs indicates radial nerve pathology, not stroke 1
• Unnecessary anticoagulation: Starting antiplatelet or anticoagulant therapy for peripheral nerve compression exposes patients to bleeding risk without benefit 1, 2
• Delayed splinting: Failure to immobilize promptly can lead to wrist drop contracture and prolonged recovery 1