What is the management for a patient presenting with a stroke manifesting as facial asymmetry on the right?

Management of Stroke Presenting with Isolated Right Facial Asymmetry

A patient presenting with isolated right facial asymmetry as the sole manifestation of stroke requires immediate emergency evaluation following published guidelines for acute stroke care, with urgent brain imaging to confirm diagnosis and determine eligibility for time-sensitive reperfusion therapies. 1

Immediate Actions and Triage

Call 9-1-1 immediately even if this is the only symptom, as isolated facial droop represents a focal neurological deficit consistent with acute stroke. 1 The patient should be transported directly to a certified stroke center emergency department, not to an outpatient clinic or primary care office. 1

Critical Time-Sensitive Information to Obtain

• Exact time of symptom onset or last known well time if onset was unwitnessed 1
• Current medications and medical history 1
• Witness contact information to verify timeline 1
• Any other subtle neurological symptoms the patient may not have recognized 1

Emergency Department Evaluation

Immediate Diagnostic Steps

Brain imaging must be performed urgently (ideally within minutes, certainly within 24 hours) using CT or MRI to differentiate ischemic from hemorrhagic stroke and exclude stroke mimics. 1 Non-contrast CT is typically first-line due to availability, though MRI is more sensitive for small or hyperacute infarcts. 1

Key clinical assessments include:

• National Institutes of Health Stroke Scale (NIHSS) to quantify severity and monitor for evolving deficits 2
• Blood glucose measurement to rule out hypoglycemia as a stroke mimic 2
• Blood pressure, complete blood count, electrolytes, renal function, coagulation studies, troponin, and ECG 1

Anatomical Localization

Right facial asymmetry (left facial droop) typically indicates ischemia in the distribution of the right internal carotid artery or right middle cerebral artery. 1 However, isolated facial weakness can also result from vertebrobasilar system involvement affecting cranial nerve nuclei. 1

Critical pitfall: Do not assume this is a peripheral facial nerve palsy (Bell's palsy). Central facial weakness from stroke typically spares the forehead due to bilateral cortical innervation of upper facial muscles, while peripheral lesions affect the entire hemiface. 3

Acute Treatment Decisions

Intravenous Thrombolysis

If presenting within 4.5 hours of symptom onset and imaging shows no hemorrhage, the patient should be evaluated for intravenous alteplase (0.9 mg/kg, 10% bolus over 1 minute, remainder over 59 minutes). 1, 4 This improves functional outcomes even for seemingly minor deficits, as isolated facial weakness can progress or indicate larger territory involvement. 4

Tenecteplase is now an acceptable alternative to alteplase with similar safety and efficacy. 5

Mechanical Thrombectomy

Vascular imaging (CTA or MRA) should be obtained to identify large vessel occlusion. 1, 2 If a large vessel occlusion is present:

• Within 6 hours: Mechanical thrombectomy significantly improves functional independence (46% vs 26.5% with medical therapy alone) 4
• Within 6-24 hours: Thrombectomy may still be beneficial if advanced imaging (MRI diffusion or CT perfusion) shows favorable ischemic penumbra-to-core ratio 4, 5

Antiplatelet Therapy

Aspirin 160-300 mg should be initiated within 48 hours of ischemic stroke onset. 1 However, aspirin should be delayed if thrombolysis is administered. 1

Risk Stratification and Secondary Prevention

High-Risk TIA vs. Minor Stroke

If imaging shows no acute infarction, this represents a TIA with extremely high early stroke risk (up to 13% within 90 days, highest in first week). 1

For high-risk TIA or minor nondisabling stroke:

• Dual antiplatelet therapy (aspirin plus clopidogrel) initiated within 24 hours and continued for 21 days reduces 90-day stroke risk from 7.8% to 5.2%. 4 This applies to patients without severe carotid stenosis or atrial fibrillation. 4
• After 3 weeks, transition to single antiplatelet therapy 4

Urgent Vascular Imaging

Carotid duplex ultrasound should be performed urgently in all patients with carotid territory symptoms who are potential candidates for revascularization. 1

If symptomatic carotid stenosis ≥50% is identified:

• Carotid endarterectomy should be performed as soon as possible, ideally within 2 weeks of symptom onset 1
• Benefit diminishes significantly after 2 weeks in women and 12 weeks in men 1
• Surgery should only be performed by specialist surgeons with very low perioperative complication rates 1

Cardiac Evaluation

Continuous cardiac monitoring should be performed to detect atrial fibrillation, as this fundamentally changes management to anticoagulation rather than antiplatelet therapy. 1 Extended monitoring (30-day event monitors) is reasonable if initial telemetry is negative. 1

Transthoracic echocardiography should be obtained to identify cardioembolic sources. 1 Transesophageal echocardiography may be considered if cryptogenic stroke is suspected. 1

Common Pitfalls to Avoid

• Do not dismiss isolated facial weakness as "too minor" for acute intervention – this represents a stroke warning sign requiring full emergency evaluation 1
• Do not delay emergency evaluation to obtain outpatient testing – immediate triage to stroke center is mandatory 1
• Do not assume symptoms will resolve – even if TIA, the recurrent stroke risk is maximal in the first 48 hours 1, 4
• Do not confuse with Bell's palsy – stroke causes central facial weakness typically sparing forehead 3