In a stroke patient with forehead paralysis, what other neurological findings should I look for and how should I manage it?

Stroke with Forehead Paralysis: Critical Diagnostic and Management Approach

Key Distinction: This Indicates Central (Upper Motor Neuron) Facial Palsy

Forehead paralysis in a stroke patient signifies involvement of the upper face, which is the hallmark of a central (cortical or subcortical) lesion rather than a peripheral facial nerve problem—this demands immediate comprehensive stroke evaluation and aggressive management. 1

The presence of forehead involvement (inability to wrinkle forehead, raise eyebrows, or close eyes completely) indicates a lower motor neuron pattern, which paradoxically suggests either:

• A pontine/brainstem stroke affecting the facial nucleus or nerve fascicle 2, 3
• Flow-limiting middle cerebral artery (MCA) disease 4

Critical Neurological Findings to Assess Immediately

Perform Standardized NIHSS Examination

Use the National Institutes of Health Stroke Scale to systematically evaluate: 1

Cranial Nerve Assessment:

• Gaze abnormalities (0=normal, 1=partial gaze palsy, 2=forced deviation) 1
• Visual field defects (hemianopia, quadrantanopia, extinction) 1
• Complete facial palsy grading (0=normal, 1=minor asymmetry, 2=partial lower face, 3=complete upper and lower face paralysis) 1

Motor Function:

• Arm drift/weakness bilaterally (test at 90° sitting or 45° supine for 10 seconds) 1
• Leg drift/weakness bilaterally (test at 30° for 5 seconds) 1
• Grade: 0=no drift, 1=drift, 2=some antigravity, 3=no antigravity, 4=no movement 1

Coordination and Sensation:

• Limb ataxia (finger-to-nose, heel-to-shin) 1
• Sensory loss (unilateral vs bilateral, mild vs severe) 1

Language and Cognition:

• Aphasia (expressive, receptive, or global) 1
• Dysarthria (slurred speech) 1
• Neglect/extinction to double simultaneous stimulation 1
• Level of consciousness (alert, drowsy, obtunded, coma) 1

Specific Red Flags for Pontine/Brainstem Involvement

When facial palsy includes forehead involvement, actively search for: 2, 3

• Conjugate gaze palsy (inability to look toward the side of lesion) 3
• Gaze-evoked nystagmus 3
• Vertigo or severe dizziness 3
• Cerebellar signs: truncal ataxia, broad-based gait, dysmetria 3
• Contralateral hemiparesis (if ventral pons involved) 2
• Altered consciousness disproportionate to imaging 5

Vascular Territory Localization

If isolated facial palsy with forehead involvement: 4

• 78% have flow-limiting mid-to-distal M1 or proximal M2 MCA disease 4
• Only 22% have traditional lacunar lesions (corona radiata or pons) 4
• Look for prominent early anterior temporal artery on imaging 4

Immediate Management Algorithm

Acute Stabilization (First 30 Minutes)

Airway and Breathing: 1

• Assess for airway compromise from decreased consciousness or brainstem dysfunction 1
• Monitor oxygen saturation continuously (target >94%) 1
• Position head of bed 20-30° if no hypoxia to optimize cerebral perfusion 1

Vital Signs: 1

• Document blood pressure (severe elevation >220 mmHg suggests hemorrhage or hypertensive encephalopathy) 1
• Check for irregular pulse (atrial fibrillation) 1
• Measure temperature every 4 hours for first 48 hours 5

Swallowing Precautions: 5

• Keep patient NPO until validated swallowing screen completed 5
• High aspiration risk with brainstem involvement 1

Diagnostic Workup

Immediate Imaging (within 25 minutes of arrival): 1

• Non-contrast CT head to exclude hemorrhage 1
• If CT negative but high suspicion: MRI with diffusion-weighted imaging (more sensitive for pontine infarcts) 2, 3
• CT angiography or MR angiography of head and neck to identify vessel occlusion/stenosis 1, 4

Laboratory Studies: 1, 5

• Glucose, electrolytes, complete blood count 5
• PT/INR, aPTT (especially if on anticoagulants) 1, 5
• Troponin and ECG (cardiac source) 1

Thrombolytic Eligibility Assessment

Time-Critical Decision (within 60 minutes): 1

• Establish exact time last known normal (not time found with symptoms) 1
• If within 3-4.5 hour window and no contraindications, consider IV tPA 1
• NIHSS score helps predict hemorrhage risk and outcome 1

Contraindications to assess: 1

• Active bleeding, recent surgery/trauma 1
• Current anticoagulation (INR >1.7) 1
• Severe hypertension (>185/110 mmHg) 1

Management of Acute Complications

Seizure Management (if occurs)

Do NOT use prophylactic anticonvulsants 5

• Prophylaxis impairs neural recovery and cognitive function 5
• No benefit in preventing post-stroke seizures 5

If seizure occurs: 5

• First-line: Lorazepam 4 mg IV at 2 mg/min 5
• Second-line: Levetiracetam 30 mg/kg IV over 5 minutes (not maintenance doses of 500-1000 mg) 5
• Avoid phenytoin due to worse cognitive outcomes 5

Monitoring: 5

• Assess for seizure activity at each vital sign check 5
• Consider continuous EEG for 24-48 hours if consciousness disproportionately reduced 5

Cerebral Edema (peaks at 3-5 days)

Risk factors: 1

• Large multilobar infarctions 1
• Cerebellar infarctions (can cause acute hydrocephalus) 1

Management: 1

• Mild fluid restriction, avoid hypoosmolar fluids (5% dextrose) 1
• Treat hypoxia, hypercarbia, hyperthermia 1
• Elevate head of bed 20-30° 1
• Avoid antihypertensives that cause cerebral vasodilation 1

Infection Prevention

Pneumonia (leading cause of post-stroke death): 1

• Early mobilization when safe 1
• Aspiration precautions until swallow screen passed 1
• Prompt antibiotic therapy if fever develops 1

Deep Vein Thrombosis: 1

• Subcutaneous anticoagulants or intermittent pneumatic compression 1
• Aspirin if anticoagulants contraindicated 1

Common Pitfalls to Avoid

1. Assuming all facial palsy without forehead involvement is Bell's palsy 2, 3

   • Pontine strokes can present as isolated LMN facial palsy 2, 3
   • Always obtain vascular imaging if other neurological symptoms present 4, 3

2. Missing evolving neurological signs 3

   • Repeat neurological examination if symptoms don't improve with initial treatment 3
   • Gaze palsy and cerebellar signs may develop after initial presentation 3

3. Inadequate vascular imaging 4

   • Comprehensive vascular imaging essential even with "isolated" facial palsy 4
   • Most cases have MCA disease, not lacunar infarcts 4

4. Using prophylactic anticonvulsants 5

   • Harms neural recovery without preventing seizures 5
   • Only treat documented seizures 5

5. Delaying thrombolytics for "minor" symptoms 1

   • Isolated facial palsy can represent significant MCA occlusion 4
   • NIHSS score guides but shouldn't exclude eligible patients 1