What to do for a patient with acute left side weakness, dizziness, nausea, and loss of balance, suspecting a stroke?

Acute Stroke Management: Immediate Action Required

This patient requires immediate 911 activation and emergency transport to a stroke center—left-sided weakness, dizziness, nausea, and loss of balance are classic stroke symptoms that demand urgent evaluation for time-sensitive thrombolytic therapy. 1

Immediate Recognition and Action

Call 911 immediately if not already done—every minute of delay results in irreversible brain tissue loss. 1, 2 The presenting symptoms of unilateral weakness, dizziness, and loss of balance meet criteria for suspected acute stroke requiring emergency response. 1

Critical Time-Sensitive Information to Obtain

• Establish exact time of symptom onset or time last known well—this determines eligibility for IV thrombolysis (3-4.5 hour window) and endovascular thrombectomy. 1, 3
• Current medications, especially anticoagulants, which affect treatment decisions. 1
• Stroke risk factors: hypertension, diabetes, atrial fibrillation, smoking history. 3
• Any recent use of phosphodiesterase-5 inhibitors (contraindication to certain treatments). 1

Prehospital Management Priorities

EMS Personnel Should:

• Use validated stroke screening tools (FAST: Face, Arms, Speech, Time) to confirm stroke suspicion. 1
• Perform a second severity screen to identify potential large vessel occlusion requiring endovascular therapy—look for aphasia, visual changes, or neglect. 1
• Check capillary blood glucose on scene to rule out hypoglycemia mimicking stroke. 1
• Minimize on-scene time to ≤20 minutes for patients within the treatment window. 1
• Provide supplementary oxygen only if oxygen saturation <94%—routine oxygen is not indicated. 1
• Avoid blood pressure treatment unless systolic BP >220 mmHg or diastolic >120 mmHg—cerebral perfusion depends on elevated BP in acute stroke. 1, 3
• Transport directly to a stroke center with neuroimaging and thrombolysis capabilities, with prearrival notification. 1

Emergency Department Evaluation

Immediate Diagnostic Steps:

• Non-contrast CT head is the minimum required imaging to exclude hemorrhage before thrombolysis. 3
• CT angiography from aortic arch to vertex to identify large vessel occlusion requiring thrombectomy. 1, 3
• 12-lead ECG to identify atrial fibrillation or other cardiac sources. 1
• NIHSS (National Institutes of Health Stroke Scale) to quantify stroke severity. 4

Critical Pitfall to Avoid:

Do not delay thrombolysis to obtain extensive vascular imaging—non-contrast CT is sufficient to initiate treatment if the patient is within the time window. 3 MRI, while more sensitive, can be falsely negative in 12% of cases within 48 hours of symptom onset. 5, 6

Localization Considerations

The combination of left-sided weakness with dizziness and loss of balance suggests either:

• Right hemisphere stroke (most likely)—contralateral motor deficits affecting the left side. 4, 3
• Brainstem stroke (less likely but critical to consider)—would typically produce crossed findings (ipsilateral facial weakness with contralateral body weakness), which should be specifically assessed. 7

Bedside Examination to Differentiate:

If the patient has acute vestibular syndrome (continuous vertigo, nystagmus, nausea/vomiting, gait instability), perform HINTS examination (Head Impulse, Nystagmus, Test of Skew), which is more sensitive than early MRI for detecting stroke. 5 However, this requires specialized training and should not delay transport. 8

Treatment Thresholds

If Presenting Within 3-4.5 Hours:

• IV thrombolysis (rtPA) if no contraindications and BP can be maintained <185/110 mmHg before and for 24 hours after treatment. 4, 3
• Endovascular thrombectomy if large vessel occlusion identified on CTA. 3

Blood Pressure Management:

• For thrombolysis candidates: Maintain BP <185/110 mmHg. 4
• For non-candidates: Treat only if BP >220/120 mmHg—aggressive BP lowering reduces cerebral perfusion and worsens outcomes. 1, 3

Post-Acute Management

Once stabilized:

• Antiplatelet therapy (aspirin, clopidogrel) for secondary prevention if ischemic stroke confirmed. 4
• Anticoagulation if cardioembolic source (e.g., atrial fibrillation) identified. 4
• Early mobilization when medically stable. 4
• Comprehensive rehabilitation addressing motor deficits, balance training, and activities of daily living. 1, 4

Key Takeaway

Time is brain tissue—the window for effective intervention is measured in minutes, not hours. 1, 2 Immediate recognition, rapid EMS transport to a stroke center, and urgent neuroimaging are the critical steps that determine whether this patient will receive life-saving treatment or suffer permanent disability. 1, 3