How should a 48-year-old man with weakness, altered mental status, and loss of motor control be evaluated and managed?

Evaluation and Management of a 48-Year-Old Male with Weakness, Altered Mental Status, and Loss of Motor Control

This patient requires immediate evaluation for acute ischemic stroke using the NIHSS (National Institutes of Health Stroke Scale), with urgent non-contrast CT head followed by consideration of IV tPA if stroke is confirmed and the patient presents within 4.5 hours of symptom onset. 1

Immediate Assessment (First 10 Minutes)

Primary Survey and Stabilization

• Position the patient supine if unconscious to ensure adequate cerebral perfusion 2
• Assess and secure airway, breathing, and circulation (ABC) before proceeding with further evaluation 2
• Obtain exact time of symptom onset or last known normal - this is critical for thrombolytic eligibility 1

Rapid Neurological Assessment Using NIHSS

Perform the complete 11-item NIHSS immediately to quantify neurological deficit and guide treatment decisions 1:

• Level of consciousness (1a-1c): Assess alertness (0=alert to 3=unarousable), orientation to age/month, and ability to follow simple commands 1
• Motor function (items 5-6): Test arm drift at 90° (sitting) or 45° (supine) for 10 seconds; test leg elevation at 30° for 5 seconds bilaterally 1
• Gaze and visual fields (items 2-3): Check horizontal eye movements and confrontational visual fields 1
• Facial symmetry (item 4): Assess for facial droop or asymmetric smile 1
• Language and speech (items 9-10): Evaluate for aphasia and dysarthria 1
• Sensory function (item 8): Test for unilateral sensory loss 1

NIHSS interpretation: Score <5 indicates small stroke; >20 indicates large stroke 1

Urgent Diagnostic Workup (Within 25 Minutes of Arrival)

Immediate Imaging

• Non-contrast CT head is the first imaging study to exclude hemorrhage before considering thrombolytic therapy 1
• CT must be completed and interpreted within 25 minutes of ED arrival to meet quality benchmarks 1

Laboratory Studies

• Complete blood count, electrolyte panel, glucose, and coagulation studies are essential before tPA administration 1
• EKG to identify atrial fibrillation or acute cardiac ischemia as potential etiology 1

Differential Diagnosis Considerations

Stroke Mimics to Exclude

Approximately 50% of suspected in-hospital strokes are ultimately stroke mimics 1:

• Toxic-metabolic encephalopathy: Check comprehensive metabolic panel, ammonia, medication levels 1
• Sedative medications: Review recent opioid and benzodiazepine administration 1
• Seizure with postictal state: Obtain history of witnessed seizure activity 1
• Hypoglycemia or hyperglycemia: Immediate fingerstick glucose 1
• Sepsis: Check vital signs, white blood cell count, lactate 1

Critical distinction: Altered mental status as the sole symptom without focal neurological findings is more likely a stroke mimic than true stroke 1

Other Neurological Emergencies

• Cauda equina syndrome: If absent lower limb reflexes with sensory level at L5, obtain urgent MRI lumbar spine without contrast 3
• Neuromuscular disorders: If progressive weakness with respiratory concerns, measure serum CK and consider urgent neurology consultation 4

Treatment Algorithm

If Acute Ischemic Stroke Confirmed (CT Negative for Hemorrhage)

IV tPA administration within 4.5 hours of symptom onset provides significant benefit 1:

• Number needed to treat = 8.3 for one additional patient to achieve minimal or no disability at 90 days 1
• 39% of tPA-treated patients achieve modified Rankin Scale 0-1 (no residual disabling symptoms) versus 26% with placebo 1
• Benefit observed in both 0-90 minute and 91-180 minute time windows 1

Accept the increased hemorrhage risk: Symptomatic intracerebral hemorrhage occurs in 6% of tPA patients versus 0.6% placebo, but overall 90-day mortality remains similar (17% tPA vs 21% placebo) 1

If Stroke Mimic Suspected

• Correct metabolic derangements: Address hypoglycemia, hyponatremia, hypercalcemia, uremia 1
• Treat underlying infection: Initiate antibiotics if sepsis identified 1
• Discontinue offending medications: Stop or reverse sedatives, anticholinergics 1
• Provide supportive care: Supplemental oxygen, blood pressure support, adequate pain control 1

Management of Altered Mental Status and Agitation

Non-Pharmacological Interventions (First-Line)

• Eliminate identified risk factors: Avoid high-risk medications, treat infections promptly, correct dehydration and electrolyte disturbances 1
• Optimize sensory environment: Use hearing aids and glasses, provide frequent reorientation, ensure adequate lighting 1
• Maximize oxygen delivery: Supplemental oxygen, blood transfusion if anemic, blood pressure support as needed 1

Chemical Restraints (Only When Absolutely Necessary)

• Limit use to situations where patient safety cannot be maintained otherwise 1
• Avoid anticholinergic medications which worsen delirium 1

Common Pitfalls to Avoid

• Do not delay imaging while attempting "conservative management" - absent reflexes with sensory level findings suggest significant neural compromise requiring urgent evaluation 3
• Do not assume writing hand definitively determines cerebral dominance - 70% of left-handed individuals lateralize language to the left hemisphere 5
• Do not wait to see if deficits resolve spontaneously - this causes critical delays in stroke treatment 1
• Do not attribute postprocedural neurological deficits to anesthesia without excluding stroke 1
• Do not overlook respiratory or swallowing concerns - these require immediate subspecialist referral for potential neuromuscular disorders 4

Disposition and Follow-Up

If Stroke Confirmed

• Admit to stroke unit or ICU for continuous monitoring 1
• Initiate secondary stroke prevention: Antiplatelet therapy, statin, blood pressure management 1
• Screen for cognitive and emotional problems at follow-up using validated instruments (MoCA, HADS) 1

If Stroke Ruled Out

• Identify and treat underlying cause before discharge 1
• Ensure safe ambulation: Perform "get up and go test" - patients unable to rise from bed, turn, and steadily ambulate should not be discharged 1
• Arrange appropriate follow-up based on identified etiology 1