What is the appropriate evaluation and management for an older adult patient presenting with left-sided body weakness and slurring of speech, potentially indicating a stroke or other acute neurological condition, with possible underlying risk factors such as hypertension (high blood pressure), diabetes, or a history of cardiovascular disease (CVD)?

Critical History and Physical Examination for Left-Sided Weakness and Slurred Speech

This presentation is acute stroke until proven otherwise—immediately establish time of symptom onset (or last known well time) as this determines eligibility for thrombolytic therapy and endovascular intervention. 1, 2

Time-Critical Initial Assessment

Establish Exact Symptom Onset Time

• Ask specifically when the patient was last at baseline neurological function 1
• If patient woke with symptoms, the "last known well" time is when they went to sleep, not when they woke 1
• This single piece of information determines whether the patient qualifies for IV tPA (within 4.5 hours) or endovascular thrombectomy (up to 24 hours for select patients) 1, 2

Rapid Stroke Assessment Using Validated Tools

Use the Cincinnati Prehospital Stroke Scale (CPSS) immediately—check for three findings: 1

• Facial droop: Have patient smile or show teeth; one side not moving equally indicates positive finding 1
• Arm drift: Patient closes eyes and holds both arms straight out for 10 seconds; one arm drifting down or not moving indicates positive finding 1
• Abnormal speech: Have patient say "you can't teach an old dog new tricks"; slurring, wrong words, or inability to speak indicates positive finding 1

A single abnormality on CPSS has 72% probability of stroke 1

Detailed Neurological History to Obtain

Symptom Characterization

• Determine if symptoms were sudden/abrupt in onset—this is the hallmark of ischemic stroke 3, 2
• Left-sided weakness distribution: Face only, arm only, leg only, or combination (helps localize lesion) 1
• Speech abnormality type: 4, 5
  • Slurred speech with intact comprehension (dysarthria—suggests brainstem or motor pathway involvement)
  • Word-finding difficulty or nonsensical speech (aphasia—suggests left hemisphere cortical involvement)
  • Inability to understand spoken language (receptive aphasia—suggests Wernicke's area)

Critical Associated Symptoms to Assess

• Visual changes: Sudden vision loss in one or both eyes, visual field cuts, double vision 1
• Sensory symptoms: Numbness or altered sensation on left side of body 1, 6
• Gait/balance: Sudden trouble walking, dizziness, loss of coordination 1
• Headache: Sudden severe headache suggests hemorrhagic stroke or subarachnoid hemorrhage 1
• Level of consciousness: Any confusion or decreased alertness 1

Stroke Risk Factors to Document

Vascular Risk Factors

• Hypertension: Most important modifiable risk factor 1
• Diabetes mellitus: Increases stroke risk and affects prognosis 1
• Atrial fibrillation: Critical for determining cardioembolic source 5, 2
• Prior stroke or TIA: Increases recurrence risk 1, 2
• Smoking status: Active smoking significantly increases risk 1
• Hyperlipidemia: Contributes to atherosclerotic disease 1
• Coronary artery disease or peripheral vascular disease: Indicates systemic atherosclerosis 1

Medication History

• Anticoagulation or antiplatelet therapy: Critical for tPA eligibility determination 1
• Recent surgery or trauma: May contraindicate thrombolysis 1

Focused Physical Examination

Vital Signs Assessment

• Blood pressure: Do NOT treat hypertension in prehospital or initial ED setting unless systolic BP >220 mmHg or diastolic >120 mmHg 1
• Oxygen saturation: Administer supplemental oxygen only if saturation <94% 1
• Blood glucose: Mandatory to exclude hypoglycemia as stroke mimic 1, 3, 2

Complete NIHSS Examination

Perform the full 11-item National Institutes of Health Stroke Scale 1:

• Level of consciousness (0-3 points): Alert, drowsy, stuporous, or coma 1
• Gaze (0-2 points): Normal, partial gaze palsy, or forced deviation 1
• Visual fields (0-3 points): No loss, partial hemianopia, or complete hemianopia 1
• Facial palsy (0-3 points): Normal, minor paralysis, partial paralysis, or complete paralysis 1
• Motor arm—both sides (0-4 points each): No drift, drift, some antigravity effort, no antigravity effort, or no movement 1
• Motor leg—both sides (0-4 points each): Same scoring as arms 1
• Limb ataxia (0-2 points): Finger-to-nose and heel-to-shin testing 1
• Sensory (0-2 points): Normal, mild-moderate unilateral loss, or total loss 1
• Language/aphasia (0-3 points): Describe picture, name objects, read sentences 1
• Dysarthria (0-2 points): Read list of words—normal, mild-moderate slurring, or severe/unintelligible 1
• Extinction/inattention (0-2 points): Simultaneous bilateral stimulation testing 1

NIHSS score interpretation: <5 indicates small stroke, >20 indicates large stroke 1

Distinguishing Stroke Location

Left Hemisphere (MCA/ICA Territory) Features

Right-sided weakness with right facial droop plus aphasia strongly suggests left MCA stroke 6:

• Aphasia presence: Language dysfunction in right-handed patients indicates left hemisphere 6, 4
• Right homonymous hemianopsia: Left visual field cut in both eyes 6
• Right-sided sensory loss: Accompanies motor deficits 6

Brainstem Stroke Features

Ipsilateral facial involvement with contralateral body weakness indicates brainstem localization 7:

• Left facial weakness WITH left body weakness = cortical or subcortical lesion 7
• Left facial weakness WITH right body weakness = brainstem lesion (crossed findings) 7
• Associated symptoms: Diplopia, vertigo, ataxia, dysphagia, dysarthria without aphasia 7

Critical Stroke Mimics to Exclude

Conditions That Can Present Identically

• Hypoglycemia: Check fingerstick glucose immediately—most common and easily reversible mimic 1, 3, 2
• Seizure with Todd's paralysis: History of seizure activity, gradual resolution over hours 3
• Complicated migraine: History of migraines, younger age, gradual onset 3
• Conversion disorder: Inconsistent examination findings, non-anatomic deficits 3
• Bell's palsy: Isolated facial weakness WITHOUT limb weakness or speech changes 8

Red Flags for Hemorrhagic Stroke

• Severe headache at onset: Suggests intracerebral hemorrhage or subarachnoid hemorrhage 1, 3
• Rapid deterioration in consciousness: More common with hemorrhage 1
• Vomiting at onset: Associated with posterior fossa hemorrhage 1

Immediate Diagnostic Testing Required

Laboratory Tests (Must Be Completed Within 60 Minutes)

The following tests are mandatory before tPA administration 1:

• Complete blood count with platelets
• PT/INR and aPTT
• Blood glucose
• Serum electrolytes and creatinine
• Troponin and ECG (high incidence of cardiac disease) 1

Neuroimaging Protocol

Non-contrast CT head is the minimum required imaging 1, 2:

• Primary purpose: Exclude intracranial hemorrhage before thrombolysis 1
• Goal: Complete CT within 25 minutes of patient arrival 1
• MRI with diffusion-weighted imaging is preferred if immediately available—more sensitive for acute ischemia, especially small brainstem strokes 7, 6, 2

CT angiography or MR angiography from aortic arch to vertex should be completed within 24 hours 6:

• Identifies large vessel occlusion requiring endovascular thrombectomy 6
• Critical for patients presenting within 24 hours of last known well 6, 2

Common Pitfalls to Avoid

• Delaying care to obtain extensive vascular imaging: Basic CT and labs should be completed first; advanced imaging should not delay tPA if patient is within treatment window 1
• Treating hypertension aggressively: Permissive hypertension is appropriate in acute stroke unless BP >220/120 mmHg 1
• Missing the time window: Every minute of delay increases disability—"time is brain" 1, 2
• Assuming isolated dysarthria is benign: Even isolated speech changes can represent acute stroke with high mortality risk, especially with concurrent infections 5
• Failing to recognize brainstem stroke: Crossed findings (ipsilateral face, contralateral body) are pathognomonic for brainstem localization 7