What is the management approach for a patient presenting with right-sided body weakness, potentially indicating a stroke or other neurological condition?

Management of Right-Sided Body Weakness

Immediately activate a stroke alert and transfer the patient to an emergency department with stroke capabilities, as right-sided weakness localizes to the left cerebral hemisphere and represents a stroke until proven otherwise. 1, 2

Immediate Priorities (Within Minutes)

Establish Time of Symptom Onset

• The single most critical piece of information is when the patient was last known to be at their normal baseline. 1
• For patients who awaken with symptoms or cannot provide history, use the time they were last known to be symptom-free. 1
• This determines eligibility for IV tPA (within 3-4.5 hours) and endovascular thrombectomy (up to 24 hours in selected cases). 2, 3

Triage as Highest Priority

• Treat this patient with the same urgency as acute myocardial infarction or major trauma, regardless of symptom severity. 1
• Request EMS prehospital notification to expedite evaluation. 1
• Activate stroke team notification in parallel with initial assessment. 1

Initial Assessment and Stabilization

ABCs and Vital Signs

• Stabilize airway, breathing, and circulation first. 1
• Do NOT aggressively treat hypertension unless BP >220/120 mmHg (or >185/110 mmHg if tPA candidate), as cerebral perfusion depends on elevated blood pressure in acute stroke. 2, 3

Neurological Examination

• Perform the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity. 1, 3
• Right-sided face, arm, and leg weakness with possible speech difficulty localizes to the left middle cerebral artery territory. 2
• A pattern of face and arm involvement without leg weakness is classic for MCA territory stroke. 2

Critical Pitfall to Avoid

• Brainstem stroke would produce ipsilateral facial weakness with contralateral body weakness—this patient has contralateral deficits on both face and body, ruling out brainstem localization. 2, 4

Neuroimaging (Urgent—Do Not Delay)

Minimum Required Imaging

• Non-contrast CT head is the minimum required to exclude intracranial hemorrhage before thrombolysis. 2
• This can be completed within 25 minutes of ED arrival per AHA time goals. 1

Additional Vascular Imaging

• CT angiography from aortic arch to vertex is necessary to identify large vessel occlusion requiring endovascular thrombectomy. 2
• However, do not delay tPA administration to obtain CTA if the patient is within the treatment window. 2

MRI Considerations

• MRI with diffusion-weighted imaging has higher sensitivity for acute ischemia but should not delay treatment if CT is immediately available. 1, 5
• MRI is particularly useful for posterior circulation strokes and small infarcts. 4

Acute Treatment Decisions

IV Thrombolysis (tPA)

• Administer IV tPA if patient presents within 3-4.5 hours of symptom onset and meets eligibility criteria. 1, 3
• Symptomatic intracerebral hemorrhage occurs in approximately 6% of tPA-treated patients, but overall 90-day outcomes are improved despite this risk. 1
• Maintain BP <185/110 mmHg before treatment and for 24 hours after tPA administration. 3

Endovascular Thrombectomy

• Consider for large vessel occlusion, potentially up to 24 hours in selected patients with favorable imaging. 2
• Transfer to comprehensive stroke center if endovascular capabilities are not available locally. 1

Secondary Assessment

Exclude Stroke Mimics

• Obtain glucose level immediately—hypoglycemia can mimic stroke. 1, 6
• Consider seizure with Todd's paralysis, complicated migraine, or conversion disorder in the differential. 1

Identify Stroke Etiology

• ECG to detect atrial fibrillation or acute myocardial infarction. 6
• Complete blood count, metabolic panel, PT/INR, and lipid panel. 6
• Echocardiogram and carotid Doppler for secondary prevention planning. 6

Risk Factor Context

• Smoking, hypertension, and stable angina (indicating systemic atherosclerosis) are major modifiable risk factors present in this patient. 2, 6
• These factors increase both stroke risk and recurrence risk, requiring aggressive secondary prevention. 6

Post-Acute Management

Antiplatelet or Anticoagulation

• Start aspirin within 24-48 hours if not receiving tPA, or after 24 hours if tPA was given. 3, 6
• Switch to anticoagulation if cardioembolic source (e.g., atrial fibrillation) is identified. 3

Early Mobilization and Rehabilitation

• Begin mobilization when medically stable. 3
• Comprehensive rehabilitation addressing motor deficits, speech/language impairments, and activities of daily living is essential for optimal recovery. 3

Monitoring for Complications

• Regular neurological assessments for deterioration in the acute phase. 3
• Screen for post-stroke depression, spasticity, and shoulder pain. 3

Prognostic Considerations

• Every minute of delay results in loss of approximately 1.9 million neurons—time is brain. 2
• Early recognition and treatment are critical for reducing mortality and morbidity. 2, 6
• Long-term follow-up is necessary to monitor recovery and adjust rehabilitation strategies. 3