What is the acute management for a patient with sudden left facial and arm numbness suggestive of an acute cerebrovascular event?

Acute Management of Left-Sided Facial and Arm Numbness

Immediately activate emergency medical services (EMS) and transport the patient to the nearest emergency department with stroke capability—this presentation represents a VERY HIGH risk acute cerebrovascular event requiring urgent brain imaging and potential thrombolytic or endovascular intervention within minutes to hours. 1

Immediate Recognition and EMS Activation

• Left facial and arm numbness indicates a right hemisphere stroke, most commonly in the right middle cerebral artery (MCA) territory, because sensory pathways cross in the brainstem producing contralateral symptoms 2, 3
• This symptom pattern—unilateral facial and limb sensory disturbance—places the patient at VERY HIGH risk for completed stroke if presenting within 48 hours of symptom onset 1
• Call 911 immediately; EMS transport is critical because prehospital notification reduces time to CT scanning and treatment 1
• Document the exact time of symptom onset (or last known normal time), as this determines eligibility for time-sensitive interventions 1, 4

Prehospital Management by EMS

• Provide supplementary oxygen only if oxygen saturation is <94% 1
• Do NOT treat blood pressure in the prehospital setting unless systolic BP <90 mm Hg (hypotension); elevated BP should not be lowered before hospital arrival 1
• Obtain focused history: time of onset, medications (especially anticoagulants), recent trauma, drug use 1
• Transport directly to a stroke center with on-site CT/MRI and access to thrombolysis and thrombectomy 1
• Provide advance notification to the receiving ED to activate stroke protocols 1

Emergency Department Evaluation (First 60 Minutes)

Immediate Diagnostic Workup

• Non-contrast CT head is mandatory within minutes of arrival to exclude hemorrhage before any antithrombotic therapy 1, 4
• CT angiography (CTA) from aortic arch to vertex should be completed within 24 hours (ideally immediately) to identify large vessel occlusion amenable to thrombectomy 1
• 12-lead ECG without delay to detect atrial fibrillation or acute coronary syndrome 1
• Laboratory tests: complete blood count, electrolytes, renal function, glucose, coagulation studies (PT/INR, aPTT), troponin 1
• MRI with diffusion-weighted imaging (DWI) is more sensitive than CT for acute infarction but should not delay treatment if CT is immediately available 2, 3

Time-Critical Treatment Decisions

Within 4.5 hours of symptom onset:

• Evaluate for intravenous thrombolysis (alteplase/tPA) if CT excludes hemorrhage and no contraindications exist 1, 3, 4
• Antiplatelet agents (aspirin, clopidogrel) must be delayed until 24 hours after thrombolysis to avoid hemorrhagic transformation 1

Within 24 hours of symptom onset:

• Assess for endovascular thrombectomy if CTA demonstrates proximal artery occlusion (right ICA or MCA) 1, 3
• Thrombectomy can be performed even if thrombolysis is contraindicated 1

If presenting beyond thrombolysis window but within 48 hours:

• Initiate dual antiplatelet therapy (aspirin 81 mg + clopidogrel 75 mg daily) for 21-30 days if diagnosis is TIA or minor nondisabling stroke, then continue aspirin monotherapy indefinitely 1
• This applies only if hemorrhage is excluded and patient is not receiving thrombolysis 1

Critical Monitoring for Complications

Malignant Cerebral Edema

• Large right MCA infarctions (>50% MCA territory or >145 mL) can cause life-threatening brain swelling within 24-96 hours 2
• Monitor continuously for deteriorating consciousness, pupillary changes, or worsening neurological deficits indicating herniation 2
• Urgent neurosurgical consultation for decompressive hemicraniectomy is recommended for patients <60 years with extensive MCA infarction to reduce mortality 1, 2, 3

Blood Pressure Management

• Do NOT aggressively lower blood pressure in acute ischemic stroke unless systolic BP >220 mm Hg or patient is receiving thrombolysis 1
• Permissive hypertension maintains cerebral perfusion to ischemic penumbra 1

Admission and Ongoing Care

• Admit to stroke unit or neuroscience intensive care unit immediately after ED stabilization 1
• Prolonged ED stays worsen outcomes; time-sensitive treatments (BP management, anticoagulation reversal if applicable) should begin in the ED 1
• Initiate multidisciplinary rehabilitation assessment early, as all ICH and stroke patients benefit from structured rehabilitation 1

Common Pitfalls to Avoid

• Do not assume symptoms are "just numbness"—sensory symptoms alone without motor weakness still constitute VERY HIGH risk if presenting within 48 hours 1
• Do not delay imaging for detailed history—physicians and nurses should work in parallel to expedite evaluation 1
• Do not give aspirin or other antiplatelets before CT excludes hemorrhage 1
• Do not dismiss right hemisphere strokes as less urgent—they carry equal risk of malignant edema and require identical acute management 2
• In dysphagic patients, aspirin can be given via enteral tube or rectal suppository (325 mg) 1