What is the management plan for a patient with unstable gait, dizziness, hemiparesis, and hemisensory loss of the face, upper limb, and lower limb?

Management of Acute Stroke with Hemiparesis and Hemisensory Loss

Immediate Emergency Management

This patient requires immediate emergency stroke protocol activation with urgent neuroimaging and consideration for thrombolytic therapy if presenting within the treatment window. 1

Initial Assessment and Stabilization

• Perform rapid ABC assessment with pulse oximetry and body temperature monitoring, examining for signs of trauma, carotid bruits, cardiac arrhythmias, and concurrent myocardial ischemia 1

• Obtain immediate non-contrast CT brain to exclude hemorrhage before any thrombolytic consideration, along with blood glucose, electrolytes, renal function, complete blood count with platelets, PT/INR, aPTT, and cardiac markers 1

• Calculate NIH Stroke Scale (NIHSS) score to quantify neurological deficit severity, identify vessel occlusion location, determine treatment eligibility, and establish prognosis 1, 2

Neurological Examination Priorities

The combination of unstable gait, dizziness, hemiparesis, and hemisensory loss affecting face, upper and lower limbs suggests a large vessel occlusion involving the middle cerebral artery territory or thalamocapsular region 3, 4

• Document motor function bilaterally using NIHSS motor arm/leg scores (0=no drift, 1=drift before 5 seconds, 2=falls before 10 seconds, 3=no antigravity effort, 4=no movement) 1

• Assess sensory deficits systematically (0=no sensory loss, 1=mild sensory loss, 2=severe sensory loss) noting that hemisensory loss involving face and all limbs indicates cortical or subcortical involvement 1, 5

• Evaluate gait and coordination for limb ataxia (0=no ataxia, 1=ataxia in 1 limb, 2=ataxia in 2 limbs) 1

• Test visual fields as dizziness with hemisensory findings may indicate posterior circulation involvement 1

Time-Critical Treatment Decisions

Thrombolytic Therapy Consideration

Do not delay thrombolytic therapy while awaiting coagulation results unless there is clinical suspicion of bleeding abnormality, thrombocytopenia, known anticoagulant use, or heparin/warfarin administration 1

• Thrombolysis must be administered within appropriate time windows based on symptom onset, with careful risk-benefit assessment 4

• Obtain neurology consultation immediately for treatment decisions and ongoing management 1

Advanced Imaging

• MRI with diffusion-weighted imaging is more sensitive than CT for detecting acute ischemic stroke, particularly in thalamic and posterior circulation strokes where CT may be falsely negative 5

• Consider CT or MR angiography to identify large vessel occlusion amenable to mechanical thrombectomy 1

Acute Inpatient Management

Monitoring and Complications Prevention

• Admit to stroke unit or intensive care setting with continuous neurological monitoring for deterioration 1

• Assess fall risk immediately as stroke patients have up to 50% fall rates, with hemiparesis, trunk instability, and decreased lower extremity function significantly increasing risk 1

• Implement aspiration precautions with swallow screening before oral intake 1

• Provide eye protection for incomplete eye closure including taping, artificial tears, eye ointment, and humidified eye chambers, with ophthalmology referral if severe 1

Early Rehabilitation Initiation

• Begin early mobilization and positioning within 24-48 hours if medically stable, avoiding prolonged positioning of joints at end range 1, 6

• Assess motor recovery patterns distinguishing between hemiplegia (complete paralysis, NIHSS motor score 3-4) and hemiparesis (weakness with some movement, NIHSS motor score 1-2), as this determines rehabilitation intensity 7

• Monitor for spasticity development as hemiplegia initially presents with flaccidity that may progress to spasticity 7

Subacute and Rehabilitation Phase

Functional Recovery Optimization

• Implement task-specific motor training focusing on normal movement patterns and gradual reintroduction to activities of daily living 6

• Address energy expenditure concerns as hemiplegic gait demonstrates up to 2 times higher oxygen cost with 50% reduced mechanical efficiency compared to able-bodied individuals 7

• Provide assistive devices and bracing as needed, recognizing that 25-50% of stroke survivors require ongoing assistance with activities of daily living 7

Follow-up and Reassessment

Patients with incomplete recovery at 3 months require referral to appropriate specialists including facial plastic surgery for persistent facial weakness, ophthalmology for ongoing eye complications, and psychology/psychiatry for depression management 1

• Schedule follow-up within 1-2 weeks to monitor recovery trajectory, identify complications, and adjust rehabilitation plans 1

• Reassess at 3 months for persistent deficits requiring reconstructive procedures or advanced rehabilitation interventions 1

Critical Pitfalls to Avoid

• Do not assume normal CT excludes stroke - obtain MRI if clinical suspicion remains high despite negative CT, particularly for thalamic or posterior circulation strokes 5

• Do not delay treatment for extensive workup - time to revascularization is the major determinant of outcome 6

• Do not overlook fall prevention - implement immediate precautions as near-falls in hospital predict repeated falls in the first 12 months post-discharge 1

• Do not confuse drowsiness with aphasia - altered arousal differs from communication deficits and requires different management 2