How should I evaluate a 44-year-old male with a history of well-controlled hypertension presenting with arm weakness?

Evaluation of Arm Weakness in a 44-Year-Old Male with Hypertension

This patient requires immediate stroke evaluation with urgent neuroimaging, as arm weakness in a hypertensive patient is a cardinal sign of acute ischemic stroke until proven otherwise.

Immediate Time-Sensitive Assessment

Critical First Steps (Within Minutes)

• Establish exact time of symptom onset – this determines eligibility for thrombolytic therapy, which has a narrow 4.5-hour window 1, 2
• Perform focused neurological examination looking specifically for:
  • Facial droop (OR 2.81 for stroke/TIA) 1
  • Arm weakness (OR 2.61 for stroke/TIA) – already present in this patient 1
  • Speech disturbance (OR 1.92 for stroke/TIA) 1
  • Pronator drift of the affected arm 2
  • Strength testing in all extremities with specific grading (0/5 to 5/5) 2

Vital Signs and Initial Measurements

• Measure blood pressure in both arms to detect discrepancies that might suggest aortic pathology or renovascular disease 3
• Document exact BP values – hypertension is common in acute stroke (patient in case series presented with 191/100 mmHg) 2
• Check oxygen saturation – low oxygen saturation is associated with non-stroke diagnoses (OR 0.41) 1
• Assess for orthostatic changes if patient is stable enough 3

Urgent Diagnostic Workup

Neuroimaging (Highest Priority)

• Obtain non-contrast CT head immediately to exclude hemorrhagic stroke before any treatment decisions 2
• If CT head is negative but clinical suspicion remains high, proceed directly to MRI brain without and with contrast – CT has significant limitations in detecting subtle ischemic pathology, missing 70% of small ischemic strokes 4
• Consider CT perfusion scan if available, as it can identify areas of ischemia not visible on standard CT 2
• CT angiogram of head and neck to evaluate for large vessel occlusion or carotid stenosis 2

Critical pitfall: Do not dismiss a negative CT as ruling out stroke – MRI detects subcortical white matter lesions and microinfarcts that CT misses, particularly important in chronic hypertensive patients 4

Laboratory Studies

• Basic metabolic panel including serum creatinine and electrolytes – severe hypokalemia can cause limb weakness mimicking stroke 5
• Complete blood count 6
• Fasting glucose or HbA1c – diabetes increases stroke risk (OR 2.0) 7
• Fasting lipid panel 8
• Urinalysis 6
• ECG to evaluate for atrial fibrillation or acute coronary syndrome 8

Risk Stratification

High-Risk Features Present in This Patient

This 44-year-old has multiple concerning features:

• Age >40 years (stroke risk increases with age, OR 1.02 per year) 1
• Arm weakness (OR 2.61 for stroke/TIA) 1
• History of hypertension – associated with small vessel disease, white matter injury, and increased stroke risk 4, 1

Additional Risk Factors to Assess

• Duration of weakness >10 minutes (OR 2.3 for stroke) 7
• History of diabetes (OR 2.0 for stroke) 7
• Speech impairment (OR 1.5 for stroke) 7
• History of cardiovascular disease 7

Differential Diagnosis Considerations

Stroke/TIA (Most Likely)

• 10.5% of TIA patients have stroke within 90 days, with 91 of 180 strokes occurring in the first 2 days 7
• Arm weakness is independently associated with stroke/TIA diagnosis 1

Hypertensive Emergency

• Screen for acute end-organ damage: fundoscopy for retinopathy, cardiovascular examination, neurological deficits 6
• If BP ≥180/110 mmHg with acute neurological symptoms, this constitutes hypertensive emergency requiring immediate evaluation 6

Metabolic Causes

• Severe hypokalemia from medication interactions (particularly if taking ACE inhibitors with herbal supplements containing glycyrrhizin) can cause limb weakness 5
• Check potassium, glucose, calcium levels

Secondary Hypertension Evaluation (If Stroke Ruled Out)

Given the patient's age (44 years), consider screening for:

• Renovascular disease – particularly in younger patients with difficult-to-control hypertension 3
• Primary aldosteronism – can present with muscle weakness from hypokalemia 3
• Obstructive sleep apnea – associated with resistant hypertension 3
• Medication/substance-induced – NSAIDs, decongestants, cocaine, amphetamines 3

Blood Pressure Management During Acute Evaluation

If Acute Ischemic Stroke Confirmed

• Permissive hypertension is the standard approach – do not lower BP acutely unless specific criteria met 9
• Only treat BP if systolic >220 mmHg or patient is receiving thrombolytic therapy 9
• If treatment required, reduce mean arterial pressure by only 10-15% to avoid worsening penumbral ischemia 9

If Hypertensive Emergency (With End-Organ Damage)

• Reduce BP by no more than 25% in the first hour, then gradually to 160/100 mmHg over 2-6 hours 6
• Use IV medications (nicardipine, labetalol) in monitored setting 6

Critical Pitfalls to Avoid

• Do not delay neuroimaging – time is brain in acute stroke 2
• Do not aggressively lower BP in acute ischemic stroke without meeting specific criteria – this worsens outcomes 9
• Do not assume "well-controlled" hypertension excludes stroke – hypertensive patients develop specific brain injury patterns including white matter disease and microinfarcts 4
• Do not miss the thrombolytic window – establish symptom onset time immediately 2
• Do not rely solely on CT – proceed to MRI if CT negative but clinical suspicion high 4

Disposition

• If stroke/TIA confirmed or highly suspected: immediate hospital admission to stroke unit 7
• 25.1% of TIA patients have stroke or other adverse events within 90 days, justifying aggressive evaluation 7
• If hypertensive urgency without end-organ damage: outpatient management may be appropriate with close follow-up 6