What is the emergency management for a patient presenting with acute right‑sided hemiparesis and cranial‑nerve deficits suggestive of a left brain‑stem or cortical stroke?

Emergency Management of Acute Right Hemiparesis with Cranial Nerve Involvement

This patient requires immediate transport to a certified stroke center with urgent non-contrast CT imaging to rule out hemorrhage, followed by CT angiography to identify large vessel occlusion, as this presentation suggests acute left hemispheric or brainstem stroke requiring time-sensitive reperfusion therapy. 1, 2

Immediate Triage and Transport

• Activate emergency medical services (EMS) to bypass non-stroke-capable hospitals and transport directly to the closest comprehensive stroke center or primary stroke center with thrombectomy capability 1
• Triage this patient with the same priority as acute myocardial infarction or major trauma, regardless of deficit severity 1
• The combination of right hemiparesis with cranial nerve deficits indicates either left cortical/subcortical stroke or brainstem involvement—both require emergent evaluation 1, 3

Emergency Department Evaluation (Target: Door-to-Imaging <25 minutes)

Immediate Stabilization

• Assess and stabilize airway, breathing, and circulation (ABCs) first 1
• Obtain vital signs with continuous cardiac monitoring for the first 24 hours to detect arrhythmias, particularly atrial fibrillation 1
• Perform rapid neurological assessment documenting specific cranial nerve deficits and motor weakness pattern 1

Urgent Neuroimaging Protocol

• Obtain non-contrast CT head immediately as the initial screening study to exclude hemorrhage and assess for acute infarct 1
  • Note: Beam hardening artifact may limit sensitivity for small brainstem infarcts on CT 1
• Proceed immediately to CT angiography (CTA) from aortic arch-to-vertex if patient presents within 6 hours to identify large vessel occlusion eligible for endovascular thrombectomy 1, 2
• Do not delay imaging or treatment decisions while waiting for complete laboratory results 1

Essential Laboratory Studies (Concurrent with Imaging)

• Draw blood work immediately but do not delay imaging: electrolytes, random glucose, complete blood count, INR/aPTT, creatinine 1
• Obtain troponin and ECG to assess for concurrent myocardial ischemia or atrial fibrillation 1, 2
• These tests should not delay treatment initiation for intravenous thrombolysis or endovascular therapy 1

Anatomical Localization and Treatment Implications

Distinguish Cortical vs. Brainstem Etiology

• Right hemiparesis with cranial nerve involvement suggests left brainstem stroke (crossed syndrome) or left cortical/subcortical stroke with cortical deficits 4, 3
• Ischemic and hemorrhagic infarcts are the most frequent cause of acute brainstem syndromes affecting multiple cranial nerves 1
• Look for specific patterns:
  • Ipsilateral cranial nerve palsy with contralateral hemiparesis = brainstem (e.g., Weber's syndrome with CN III palsy) 4
  • Right hemiparesis with aphasia, neglect, or hemianopia = left cortical stroke 5, 6
  • Note: 19.4% of cortical strokes may lack obvious cortical signs initially 5

Acute Reperfusion Therapy Decision-Making

Intravenous Thrombolysis (if within 4.5 hours)

• If non-contrast CT shows no hemorrhage and patient presents within 4.5 hours of symptom onset, evaluate immediately for IV alteplase (0.9 mg/kg, 10% bolus over 1 minute, remainder over 59 minutes) 2, 7
• Maintain blood pressure <180/105 mmHg if thrombolysis is administered 2

Endovascular Thrombectomy (if within 6-24 hours)

• Use validated triage tool (such as ASPECTS) to rapidly identify EVT candidates who may require transfer 1
• CTA findings of large vessel occlusion warrant immediate consideration for mechanical thrombectomy 1, 2
• Advanced imaging (CT perfusion or multiphase CTA) can aid patient selection but must not delay treatment decisions 1

Acute Blood Pressure Management

• If thrombolysis given: Maintain BP <180/105 mmHg 2
• If no thrombolysis: Permissive hypertension may be allowed initially to maintain cerebral perfusion 2
• Avoid aggressive BP lowering in acute phase unless hypertensive emergency (>220/120 mmHg) 1

Hospital Admission and Monitoring

• Admit to specialized stroke unit or neuro-intensive care unit for continuous monitoring 2
• Monitor for neurological deterioration (occurs in 25% of patients): stroke progression, cerebral edema, or hemorrhagic transformation 1
• Assess for seizures: If seizure occurs at onset or within 24 hours, treat with short-acting medication (lorazepam IV) if not self-limited, but do not initiate long-term anticonvulsants for single seizure 1
• Monitor for complications: DVT/PE prophylaxis with LMWH (enoxaparin 40mg daily preferred over UFH), aspiration pneumonia prevention, UTI prevention 1

Secondary Prevention Workup (After Acute Phase)

• Comprehensive vascular imaging: Carotid duplex ultrasound to evaluate for stenosis 2, 7
• Cardiac evaluation: Extended cardiac monitoring (24-hour Holter or event recorder) to detect paroxysmal atrial fibrillation 1, 7
• Risk factor modification: Antiplatelet therapy, high-intensity statin, blood pressure control, diabetes management, smoking cessation 2

Critical Pitfalls to Avoid

• Do not mistake spinal epidural hematoma for stroke: Acute neck pain with hemiparesis should prompt consideration of spinal imaging before thrombolysis 8
• Do not underrecognize right hemispheric dysfunction: Patients with right hemispheric strokes present later and have lower rates of receiving thrombolysis 6
• Do not delay treatment for complete etiological workup: Treatment decisions must be made rapidly based on initial imaging in the acute phase 2
• Do not use prophylactic anticonvulsants: No evidence supports this practice and may harm neural recovery 1