What is the initial management for a patient presenting with left-sided weakness without other motor or sensory deficits, suggesting a potential stroke?

Initial Management of Left-Sided Weakness Suggesting Acute Stroke

A patient presenting with isolated left-sided weakness requires immediate transfer to an emergency department with advanced stroke care capabilities, urgent brain imaging (CT or MRI), vascular imaging (CTA or MRA from aortic arch to vertex), and ECG—all completed without delay, as this represents a highest-risk presentation for stroke. 1

Risk Stratification and Timing

The timing of symptom onset determines urgency and dictates management pathways:

Highest Risk: Symptom Onset Within 48 Hours

• Patients with unilateral weakness (face, arm, and/or leg) presenting within 48 hours are at highest risk for stroke or recurrent stroke. 1

• These patients must be immediately sent to an ED with capacity for advanced stroke care, including on-site brain and vascular imaging and ideally access to thrombolytic therapy (tPA) and endovascular interventions. 1

• The left-sided weakness in your patient indicates a likely right hemisphere stroke, as strokes cause contralateral deficits due to decussation of the corticospinal tract in the medulla. 2

High Risk: Symptom Onset Between 48 Hours and 2 Weeks

• Patients presenting between 48 hours and 2 weeks with unilateral weakness remain at high risk and should receive comprehensive evaluation by stroke expertise within 24 hours of first healthcare contact. 1

Lower Risk: Symptom Onset Greater Than 2 Weeks

• Patients presenting more than 2 weeks after symptom onset may be evaluated less urgently, ideally within one month by a neurologist or stroke specialist. 1

Essential Immediate Investigations

Neuroimaging (Without Delay)

• Brain imaging with CT or MRI must be completed urgently to differentiate ischemic stroke from hemorrhagic stroke and exclude other pathology. 1

• Noninvasive vascular imaging (CTA or MRA from aortic arch to vertex) should be performed as soon as possible, ideally within 24 hours. 1

• CTA including extracranial and intracranial vasculature from aortic arch to vertex, performed at the time of initial brain CT, is the ideal method to assess both circulations simultaneously. 1

• Vascular imaging is critical to identify significant symptomatic extracranial carotid artery stenosis requiring possible carotid revascularization. 1

• Carotid ultrasound (for extracranial imaging) and MR angiography are acceptable alternatives to CTA based on immediate availability and patient characteristics. 1

Cardiac Evaluation

• A 12-lead electrocardiogram should be completed without delay to assess for atrial fibrillation and other cardiac sources of embolism. 1

Laboratory Investigations

Initial bloodwork should include: 1

• Complete blood count (hematology)
• Electrolytes
• Coagulation studies (aPTT, INR)
• Renal function (creatinine, e-GFR)
• Random glucose or capillary glucose
• Troponin

Subsequent laboratory tests may include: 1

• Lipid profile (fasting or nonfasting)
• Hemoglobin A1c for diabetes screening
• Additional tests based on clinical suspicion

Critical Clinical Considerations

Thrombolysis Window

• If the patient presents within 4.5 hours of last known well, immediate assessment for intravenous recombinant tissue plasminogen activator (tPA) eligibility is essential. 3

• Specialized MRI studies can extend the treatment window to 9 hours in selected patients. 3

• Patients with large vessel occlusions presenting within 24 hours should be evaluated for endovascular interventions. 3

Stroke Mimics to Exclude

Common conditions that can mimic stroke include seizure, conversion disorder, migraine headache, and hypoglycemia—history and diagnostic studies typically exclude these. 4

Assessment Tools

• The National Institutes of Health Stroke Scale (NIHSS) should be used to determine stroke severity and monitor for evolving changes in clinical presentation. 3

Common Pitfalls

• Do not delay imaging or transfer while awaiting laboratory results. The priority is rapid neuroimaging and vascular assessment. 1

• Do not assume isolated motor weakness is "minor" or can wait. Unilateral weakness without other deficits still represents highest-risk presentation requiring immediate evaluation. 1

• Do not forget to establish "last known well" time precisely. This determines eligibility for time-sensitive interventions. 3

• Do not overlook the need for comprehensive vascular imaging from aortic arch to vertex. Extracranial imaging alone may miss intracranial pathology. 1