What is the likely diagnosis and management for a smoker with hypertension (HTN) and stable angina, presenting with right-sided weakness, including weakness of the right side of the face and right hand, and difficulty speaking, and what is the likely location of the stroke?

Acute Left Hemispheric Ischemic Stroke

This patient is experiencing an acute left hemispheric ischemic stroke affecting the middle cerebral artery territory, and requires immediate emergency department transfer for consideration of thrombolytic therapy and endovascular intervention.

Diagnosis and Stroke Localization

The combination of right-sided facial weakness, right hand weakness, and speech difficulty localizes to the left cerebral hemisphere, specifically the left middle cerebral artery (MCA) distribution. 1, 2

Why Left Hemisphere:

• Contralateral motor deficits (right-sided weakness affecting face and hand) indicate damage to the left motor cortex or descending motor pathways 1
• Speech disturbance (aphasia or dysarthria) strongly suggests left hemisphere involvement in this right-handed patient, as language centers are typically left-lateralized 3
• The pattern of face and arm involvement without leg weakness is classic for MCA territory stroke 2

Distinguishing from Brainstem Stroke:

• A brainstem stroke would produce ipsilateral facial weakness with contralateral body weakness (crossed findings), which this patient does not have 1
• Pure contralateral deficits affecting both face and body on the same side indicate a supratentorial (cortical or subcortical) lesion, not brainstem 1

Immediate Management Priority

This patient meets criteria for HIGHEST risk of stroke recurrence and requires immediate ED transfer with stroke center capabilities. 4

Time-Critical Actions:

• Establish exact time of symptom onset or "last known well" time to determine eligibility for IV tPA (within 4.5 hours) or endovascular thrombectomy (up to 24 hours in select patients) 2
• If patient woke with symptoms, the "last known well" time is when they went to sleep, not when they woke 2
• Transfer immediately to ED with capacity for advanced stroke care, including on-site brain and vascular imaging and access to tPA 4

Required Urgent Investigations (Without Delay):

• Non-contrast CT head as minimum required imaging to exclude intracranial hemorrhage before thrombolysis 2
• CT angiography (CTA) from aortic arch to vertex to identify large vessel occlusion requiring endovascular thrombectomy 4, 2
• Electrocardiogram to assess for atrial fibrillation as stroke mechanism 4
• Laboratory tests within 60 minutes: complete blood count with platelets, serum electrolytes and creatinine, troponin 2

Risk Factor Profile

This patient has multiple vascular risk factors that increase stroke risk and influence secondary prevention:

• Smoking - major modifiable risk factor 2
• Hypertension - most important modifiable risk factor 2
• Stable angina - indicates coronary artery disease and systemic atherosclerosis 2

Critical Pitfalls to Avoid

• Do NOT delay care to obtain extensive vascular imaging - non-contrast CT is sufficient to initiate thrombolysis 2
• Do NOT treat hypertension aggressively in acute stroke unless BP >185/110 mmHg for tPA candidates or >220/120 mmHg otherwise, as cerebral perfusion depends on elevated BP 2
• Do NOT miss the time window - every minute counts ("time is brain") 2
• Do NOT assume this could be Bell's palsy - the presence of limb weakness and speech difficulty immediately distinguishes this from peripheral facial nerve palsy 1, 5

Prognosis Considerations

The early recognition and treatment of this patient is critical for mortality and morbidity reduction. The patient's presentation within the potential thrombolysis window offers the best chance for meaningful recovery and prevention of permanent disability. 4, 2