I have a sudden right‑hand droop with inability to move the hand and a hanging posture—could this be a stroke or radial nerve palsy, and what emergency steps should be taken?

Sudden Right Hand Droop: Emergency Stroke Management

This is a stroke until proven otherwise—call 911 immediately and activate emergency medical services for high-priority transport to a comprehensive stroke center. 1, 2, 3

Why This is Most Likely a Stroke

Sudden unilateral hand weakness with a "hanging" posture represents a very high-risk presentation for acute ischemic stroke, not radial nerve palsy. 1, 2, 4 The key distinguishing features are:

• Acute onset (sudden, not gradual) strongly favors stroke over peripheral nerve compression 5, 6
• No sensory loss or paresthesias can occur in "cortical hand" strokes affecting the motor cortex hand area 5, 6
• Radial nerve palsy typically includes numbness over the dorsum of the 1st-3rd fingers and results from prolonged compression (sleeping in awkward positions, "Saturday night palsy") 7
• Stroke can mimic peripheral nerve patterns ("pseudoradial nerve palsy"), making this a critical diagnostic pitfall 6, 8

Immediate Actions (Within Minutes)

Call 911 now—do not attempt to drive to the hospital or wait to see if symptoms resolve. 1, 2, 3

• Emergency dispatch must be notified this is a suspected stroke for high-priority response 1, 3
• Document the exact time symptoms started or last time the patient was normal—this determines eligibility for clot-busting therapy (3-4.5 hour window for IV tPA) 1, 2, 4
• If symptoms began upon waking, the "last known normal" time is when the patient went to sleep 1

EMS Assessment En Route

Paramedics will perform the Cincinnati Prehospital Stroke Scale, checking for: 1, 3

• Facial droop (smile or show teeth—both sides should move equally)
• Arm drift (hold both arms straight out with eyes closed for 10 seconds—one arm drifting down is abnormal)
• Abnormal speech (slurred words or inability to speak)

If any one of these is abnormal, stroke probability is 72%. 1

Emergency Department Priorities

Immediate Imaging (Within 24 Hours, Ideally Upon Arrival)

• Brain MRI with diffusion-weighted imaging (preferred) or CT head without contrast to rule out hemorrhage 1, 2, 4
• CTA or MRA from aortic arch to vertex to identify vascular occlusion and assess for large vessel occlusion amenable to thrombectomy 1, 2, 4
• 12-lead ECG immediately to identify atrial fibrillation or cardioembolic sources 1, 2, 4

Acute Treatment Window

IV thrombolysis (rtPA) must be given within 3-4.5 hours of symptom onset if the patient meets eligibility criteria (no hemorrhage on imaging, blood pressure <185/110 mmHg). 2, 4

Endovascular thrombectomy should be considered if large vessel occlusion is identified on vascular imaging. 2

Critical Diagnostic Pitfalls to Avoid

• Do not assume this is radial nerve palsy based on the "wrist drop" appearance—stroke affecting the "hand knob" of the motor cortex or cerebral peduncle can produce identical findings 5, 6, 8
• Do not wait for sensory symptoms—pure motor strokes without sensory deficits are common in cortical hand presentations 5, 6
• Do not delay imaging to obtain nerve conduction studies—these are only appropriate after stroke is excluded 6, 8, 7
• Do not discharge if symptoms are fluctuating or crescendo—this indicates very high risk for completed stroke 4, 3

Risk Stratification

This patient meets criteria for VERY HIGH risk (symptom onset within 48 hours with unilateral weakness), requiring: 1, 4

• Immediate ED evaluation with advanced stroke care capabilities
• Brain and vascular imaging within 24 hours (ideally immediately)
• Comprehensive stroke workup including prolonged cardiac monitoring and echocardiography 2, 4

Post-Acute Management

Once stroke is confirmed: 2, 4

• Antiplatelet therapy (aspirin, clopidogrel, or combination) for secondary prevention
• Anticoagulation if cardioembolic source identified (e.g., atrial fibrillation)
• Comprehensive rehabilitation addressing motor deficits once medically stable

When It Actually Is Radial Nerve Palsy

If stroke is definitively ruled out by imaging and examination, radial nerve palsy typically: 7

• Follows prolonged compression (sleeping with arm over chair, under pillow, or while intoxicated)
• Includes paresthesias on dorsum of 1st-3rd fingers
• Shows delayed nerve conduction velocity on electrophysiologic testing after 2 weeks
• Improves spontaneously within 2-4 weeks with good prognosis

However, given the acute presentation and high stakes, stroke must be excluded first with urgent imaging. 5, 6, 8