What is the acute management for a patient with a right upper‑motor‑neuron facial palsy and right‑sided grade 0 hemiplegia?

Acute Management of Right Upper Motor Neuron Facial Palsy with Right Grade 0 Hemiplegia

This is a stroke until proven otherwise and requires immediate stroke protocol activation, not Bell's palsy treatment.

The combination of right-sided UMN facial palsy (forehead sparing) with right-sided hemiplegia indicates a LEFT hemisphere stroke affecting the motor cortex or internal capsule, and the patient requires urgent neuroimaging, stroke team activation, and consideration for thrombolysis or thrombectomy within the appropriate time window. 1, 2, 3

Critical Diagnostic Distinction

• Right UMN facial palsy with right hemiplegia is anatomically consistent with a left cerebral hemisphere lesion, as the corticospinal and corticobulbar tracts cross at different levels, producing ipsilateral facial weakness and ipsilateral limb weakness relative to the stroke side. 2, 3, 4

• The presence of any limb weakness alongside facial palsy immediately excludes Bell's palsy and mandates urgent stroke evaluation, as Bell's palsy is an isolated peripheral facial nerve disorder without other neurological deficits. 1, 5, 2

• UMN facial palsy is characterized by forehead sparing (patient can wrinkle forehead and close eyes) because the upper facial muscles receive bilateral cortical innervation, whereas lower facial muscles receive predominantly contralateral innervation. 4, 6

Immediate Management Algorithm

Within First 10 Minutes

• Activate stroke code immediately and obtain vital signs, fingerstick glucose, and establish IV access. 2, 3

• Perform rapid NIHSS assessment to quantify stroke severity, as higher NIHSS scores correlate with greater facial and limb involvement. 4

• Obtain stat non-contrast CT head to exclude hemorrhage before considering thrombolytic therapy. 2, 3

• Document exact time of symptom onset or last known well time to determine eligibility for reperfusion therapy (IV tPA within 4.5 hours, mechanical thrombectomy within 24 hours for large vessel occlusion). 2, 3

Within 30-45 Minutes

• Obtain CT angiography of head and neck to identify large vessel occlusion requiring mechanical thrombectomy. 2, 3

• Administer IV alteplase (0.9 mg/kg, maximum 90 mg) if within 4.5 hours of onset and no contraindications exist. 2, 3

• Consult interventional neuroradiology for potential mechanical thrombectomy if large vessel occlusion is identified. 2, 3

Concurrent Supportive Measures

• Implement eye protection immediately with lubricating drops every 1-2 hours while awake and ophthalmic ointment at bedtime, as facial weakness impairs eye closure and risks corneal exposure. 1, 7

• Maintain blood pressure permissively elevated (systolic 140-220 mmHg) unless thrombolysis is planned, to preserve cerebral perfusion to penumbral tissue. 2, 3

• Position head of bed at 30 degrees and maintain normothermia and normoglycemia. 2, 3

Common Diagnostic Pitfalls to Avoid

• Do not assume peripheral facial palsy based on facial weakness alone—the presence of hemiplegia definitively indicates central pathology requiring stroke workup. 1, 5, 2

• Do not delay imaging for "observation"—every minute counts in acute stroke, and the combination of facial palsy with limb weakness has 100% specificity for central lesion. 2, 3

• Do not prescribe corticosteroids (prednisolone/prednisone), as these are indicated only for Bell's palsy, which is excluded by the presence of hemiplegia. 1, 5

• Do not miss subtle upper facial weakness in stroke patients—recent evidence shows 76% of central facial palsy cases demonstrate some upper facial involvement, particularly with tight eye closure, challenging the traditional "forehead sparing" dogma. 4

• Recognize that "grade 0" hemiplegia (no visible movement) indicates severe stroke requiring aggressive intervention, as this represents complete loss of motor function. 4

Atypical Presentations Requiring Heightened Awareness

• Young patients without vascular risk factors can still have stroke, and the presence of LMN-appearing facial palsy with other neurological signs (vertigo, gaze palsy, ataxia) may indicate brainstem stroke affecting the facial colliculus. 2

• Ipsilateral central facial palsy with contralateral hemiparesis can occur with medullary infarction due to aberrant corticobulbar fiber pathways, though this is rare. 8

• Frontal lobe ischemic stroke can occasionally present with peripheral-appearing facial palsy, emphasizing the need for detailed neurological examination beyond facial assessment. 3

Post-Acute Management Considerations

• Reassess for new or worsening neurological findings at any point, as evolving stroke symptoms require repeat imaging. 1, 2

• Continue eye protection measures throughout hospitalization and after discharge if facial weakness persists, with ophthalmology referral if corneal symptoms develop. 1, 7

• Refer to facial nerve specialist if facial recovery is incomplete at 3 months, though stroke-related facial palsy typically has poorer recovery than Bell's palsy. 1