How to manage a 2-hour history of sudden onset right upper and lower limbs weakness in a patient?

Management of Acute Right-Sided Hemiparesis (2-Hour Onset)

This patient requires immediate transfer to an emergency department with advanced stroke capabilities for urgent brain imaging within 24 hours, as sudden onset unilateral weakness within 48 hours places them in the VERY HIGH risk category for stroke with up to 10% risk of recurrent events within the first week. 1, 2

Immediate Actions (Within Minutes)

Time-Critical Assessment

• Establish exact time of symptom onset or last known normal time to determine eligibility for IV thrombolysis (4.5-hour window) and endovascular thrombectomy (up to 24 hours in select cases) 2, 3
• Check bedside blood glucose immediately to rule out hypoglycemia as a stroke mimic—this is a critical first step before any imaging 2, 3
• Activate emergency medical services for immediate transfer to a stroke center with on-site CT/MRI, vascular imaging capabilities, and access to acute stroke treatments 1, 2

Focused Neurological Examination

• Assess facial weakness, arm drift, and speech disturbance using validated stroke screening tools (Cincinnati Prehospital Stroke Scale has 59% sensitivity and 89% specificity when any single abnormality is present) 3
• Evaluate for middle cerebral artery (MCA) territory involvement by checking for the triad of facial weakness, arm weakness, and speech disturbance, which has 72% probability of stroke 3
• Test reflexes bilaterally—preserved or initially normal reflexes suggest stroke, while decreased/absent reflexes with bilateral symmetric weakness suggest Guillain-Barré syndrome 2, 4
• Document progression pattern—sudden onset with maximal deficit at onset favors stroke, while ascending weakness starting distally suggests GBS 2, 4

Urgent Investigations (Within 24 Hours)

Neuroimaging (Priority #1)

• Urgent non-contrast CT brain or MRI must be completed as soon as possible within 24 hours to differentiate ischemic from hemorrhagic stroke—this is the single most critical investigation 1, 2, 3
• Noninvasive vascular imaging (CTA or MRA from aortic arch to vertex) should be completed within 24 hours to identify large vessel occlusion and assess for carotid stenosis requiring revascularization 1, 5, 3

Cardiac Evaluation

• 12-lead ECG without delay to evaluate for atrial fibrillation (independent predictor of early hospital arrival and embolic source) or acute cardiac event 1, 5, 6
• Extended cardiac monitoring should be considered if paroxysmal atrial fibrillation is suspected 3

Laboratory Studies

• Complete blood count, serum electrolytes, creatinine, and fasting blood glucose (though do not delay imaging for laboratory results—brain imaging takes absolute priority) 3

Treatment Approach

Acute Stroke Management

• If ischemic stroke confirmed and within treatment window, initiate IV thrombolysis or endovascular thrombectomy per institutional protocols 2, 3
• Monitor for malignant cerebral edema in large MCA infarctions, especially in patients under 60 years who may require decompressive hemicraniectomy 3
• Initiate secondary stroke prevention strategies immediately, including antiplatelets, anticoagulants (if cardioembolic source identified), antihypertensive agents, and lipid-lowering therapy 1

If Carotid Stenosis Identified

• Refer for possible carotid revascularization (endarterectomy or stenting) if significant extracranial carotid stenosis is identified on vascular imaging 5

Critical Pitfalls to Avoid

• Do not assume symptoms are "too mild" to be stroke—even transient unilateral weakness carries 10% risk of completed stroke within one week and requires the same urgent evaluation 3
• Do not delay transfer waiting for "complete workup"—the patient needs advanced stroke center capabilities immediately, not a comprehensive evaluation at a facility without stroke treatment capacity 1, 2
• Do not miss atypical presentations—while bilateral weakness is uncommon in stroke, basilar artery thrombosis, multiple embolic events, or progressive thrombotic stroke can cause bilateral involvement and represents extremely high-risk pathology 2
• Do not forget to check glucose—hypoglycemia can cause focal neurological deficits that perfectly mimic stroke and is immediately reversible 2, 3

Risk Stratification Context

The 2-hour timeframe places this patient in the highest risk category, with stroke recurrence rates of 1.5% at 2 days, 2.1% at 7 days, and 2.8% at 30 days even with optimal modern management through rapid-access stroke clinics 1. Historical cohorts without immediate access to stroke prevention strategies showed 90-day recurrence rates of 10.3% compared to 2.1% with immediate specialized care 1.