Can a severe cough cause a transient focal neurological deficit such as facial droop and unilateral weakness in an otherwise healthy adult?

Cough-Induced Transient Focal Neurological Deficits

Yes, severe coughing can cause transient focal neurological deficits including facial droop and unilateral weakness, but this is an extremely rare hemodynamic phenomenon that occurs only in patients with severe cerebrovascular disease, and stroke must be immediately ruled out before attributing symptoms to cough. 1

The Documented Phenomenon

A case report describes a 65-year-old man who experienced right arm and face weakness specifically associated with severe coughing fits 1. Investigation revealed:

• Complete occlusion of the left common and internal carotid arteries
• Incomplete circle of Willis (inadequate collateral circulation)
• Reconstitution of blood flow through the external carotid artery that collateralized with the intracranial internal carotid artery 1

The mechanism involves cough-induced hemodynamic changes in patients with critically compromised cerebral perfusion. When this patient coughed, the markedly elevated intrathoracic pressures reduced cardiac output and systemic blood pressure, causing transient cerebral hypoperfusion in brain regions already receiving marginal blood flow 2, 1. The symptoms completely resolved after surgical revascularization (subclavian-to-external carotid artery bypass), confirming the hemodynamic etiology 1.

Critical Pathophysiology

Severe coughing generates extremely high intrathoracic pressures that can cause multiple cardiovascular effects 2:

• Diminished cardiac output leading to decreased systemic blood pressure and cerebral hypoperfusion
• Increased cerebrospinal fluid pressure causing increased extravascular pressure around cranial vessels, further reducing brain perfusion
• Neurally mediated reflex vasodepressor-bradycardia response to cough 2

However, focal neurological deficits from cough occur ONLY when there is pre-existing severe cerebrovascular disease with inadequate collateral circulation. 1

Immediate Clinical Action Required

Any patient presenting with facial droop and unilateral weakness must be treated as having acute stroke until proven otherwise, regardless of temporal association with cough. 3

Mandatory Emergency Evaluation:

• Activate emergency medical services immediately - the combination of facial weakness and arm weakness has a 72% probability of stroke 3
• Establish exact time of symptom onset or last known normal time to determine treatment eligibility 3, 4
• Check bedside glucose immediately to rule out hypoglycemia as a stroke mimic 3, 4
• Urgent brain imaging (CT or MRI) must be completed without delay to differentiate ischemic from hemorrhagic stroke 3
• Non-invasive vascular imaging (CTA or MRA from aortic arch to vertex) should be performed within 24 hours 3

Why This Approach is Non-Negotiable:

• Patients with unilateral weakness are at VERY HIGH risk for recurrent stroke, with up to 10% risk within the first week and highest risk in the first 48 hours 3, 4
• Middle cerebral artery territory stroke is the most likely diagnosis when facial weakness, arm weakness, and speech disturbance occur together 3
• The combination of facial droop and arm weakness represents two of the three cardinal stroke signs, with 88% of all strokes presenting with at least one of these features 3

When to Consider Cough as the Etiology

Only after comprehensive stroke workup is negative should cough-induced hemodynamic compromise be considered. The following findings would support this rare diagnosis:

• Documented severe cerebrovascular disease: Complete or near-complete occlusion of major cerebral vessels with inadequate collateral circulation 1
• Strict temporal relationship: Symptoms occur exclusively during or immediately after severe coughing episodes and resolve completely within minutes 1
• Reproducibility: Symptoms consistently triggered by coughing fits 1
• Vascular imaging demonstrates: Critical stenosis or occlusion with marginal cerebral perfusion 1

Other Cough-Related Neurological Phenomena (Not Focal Weakness)

While cough can cause various neurological symptoms, these differ fundamentally from focal weakness:

• Cough syncope: Loss of consciousness following cough, typically in middle-aged, overweight males with obstructive airways disease, caused by markedly elevated intrathoracic pressures 2
• Cough headache: Headache triggered by coughing, not associated with focal deficits 5
• Cough as a neurological sign: Cough reflex sensitivity can be altered in various neurological disorders (increased in brainstem lesions, Tourette syndrome; decreased in Parkinson's disease, stroke, multiple sclerosis), but these represent chronic conditions affecting cough sensitivity, not acute focal deficits caused by coughing 5

Common Pitfalls to Avoid

• Never assume transient symptoms are "too mild" to be stroke - even brief symptoms carry 10% risk of completed stroke within one week 3
• Do not delay imaging for laboratory results - brain imaging takes priority over all other testing 3
• Do not attribute focal neurological deficits to cough without comprehensive vascular evaluation - this is an extraordinarily rare phenomenon requiring severe pre-existing cerebrovascular disease 1
• Do not confuse cough syncope (loss of consciousness) with focal neurological deficits - these are distinct phenomena with different mechanisms 2

Treatment Approach if Cough-Induced Hemodynamic TIA is Confirmed

If vascular imaging confirms critical cerebrovascular disease with cough-induced symptoms, revascularization should be considered. 1 The documented case achieved complete symptom resolution with surgical bypass 1.

Simultaneously, the underlying cause of severe cough must be thoroughly evaluated and treated, as elimination of cough will eliminate the resultant neurological episodes 2. This requires evaluation for common causes of chronic cough including upper airway cough syndrome, asthma, gastroesophageal reflux disease, and other conditions outlined in cough management guidelines 6.