What is the appropriate emergency management for an adult with new‑onset left‑arm weakness and sensory loss of unknown duration?

Management of Weakness and Numbness of Upper Left Extremity

Treat this as acute ischemic stroke until proven otherwise—immediately activate stroke protocols, obtain non-contrast head CT within 25 minutes, and prepare for IV alteplase if the patient presents within 4.5 hours of last known well and meets eligibility criteria. 1

Immediate Emergency Assessment (First 15 Minutes)

Time is brain—every 15-minute delay in treatment increases in-hospital mortality by 5%. 1

Critical Initial Steps

• Stabilize airway, breathing, and circulation while simultaneously beginning stroke evaluation—do not delay assessment for stabilization unless the airway is compromised. 1, 2

• Determine the exact time of last known well (when patient was last seen at baseline without symptoms)—this is zero-hour for all treatment decisions and determines thrombolysis eligibility. 1, 2

• Obtain fingerstick glucose immediately to rule out hypoglycemia as a stroke mimic. 1, 2

• Calculate NIHSS score to quantify stroke severity and guide treatment intensity. 1, 2

• Monitor oxygen saturation with pulse oximetry and maintain target ≥92%; administer supplemental oxygen only if hypoxemic (saturation <94%). 3

Diagnostic Imaging Protocol

• Obtain non-contrast head CT within 25 minutes of arrival to exclude hemorrhage and identify early ischemic changes—this is the single most critical diagnostic step. 1, 2

• CT interpretation must occur within 45 minutes (door-to-interpretation time) for thrombolytic candidates. 1, 2

• Add CT angiography if considering endovascular thrombectomy to identify large vessel occlusion. 1

• Emergency treatment should NOT be delayed to obtain multimodal imaging studies (Class III recommendation). 3

Essential Laboratory Tests

• Blood glucose, electrolytes, renal function, PT/INR, aPTT, complete blood count—obtain during initial evaluation but do not delay imaging or treatment. 2

• 12-lead ECG due to high incidence of cardiac disease in stroke patients. 2

Blood Pressure Management

Permissive hypertension is recommended unless thrombolysis is planned or BP exceeds 220/120 mmHg—aggressive lowering jeopardizes penumbral perfusion. 1

If Thrombolysis is Planned

• Reduce BP to <185/110 mmHg BEFORE starting alteplase (Class I, Level B). 1

• Maintain BP ≤180/105 mmHg during and for 24 hours after alteplase infusion (Class I, Level B). 1

If Thrombolysis is NOT Planned

• Do not treat BP unless systolic ≥220 mmHg or diastolic ≥120 mmHg (Class III, Level A)—lowering BP in the first 48-72 hours does not reduce death or dependency and may worsen outcomes. 1

• If BP is ≥220/120 mmHg, consider modest reduction of approximately 15% during first 24 hours, though benefit is uncertain (Class IIb, Level C). 1

Thrombolytic Therapy Decision

IV alteplase 0.9 mg/kg (maximum 90 mg) is the single most critical intervention for acute ischemic stroke and must be administered within 3-4.5 hours of symptom onset if eligible. 1, 2

Dosing Protocol

• 10% as bolus over 1 minute, remaining 90% infused over 60 minutes. 1

• Treatment within 90 minutes of onset is most likely to result in favorable outcomes—every 30-minute delay reduces probability of favorable outcome by 10.6%. 1

Monitoring During Thrombolysis

• NIHSS every 15 minutes during infusion, then hourly for 6 hours, then every 2 hours for 18 hours. 4

• Maintain strict BP control ≤180/105 mmHg throughout infusion and for 24 hours after. 1, 4

Antiplatelet Therapy

Start aspirin 325 mg within 24-48 hours after stroke onset, but NEVER within 24 hours of alteplase. 1

• If thrombolysis given, wait 24 hours and obtain repeat head CT to exclude hemorrhage before starting aspirin (Class I, Level A). 1, 4

• Aspirin is NOT a substitute for IV alteplase in patients who meet thrombolysis criteria—do not delay alteplase to give aspirin. 1

• Clopidogrel alone or combined with aspirin is NOT recommended for acute ischemic stroke (Class III, Level C). 1

Anticoagulation

Do NOT use full-dose unfractionated heparin or low-molecular-weight heparin for acute ischemic stroke—they do not improve outcomes and increase hemorrhage risk (Class III, Level A). 1

• Emergency anticoagulation does not lower risk of early recurrent stroke, even with cardioembolic sources (Class III, Level B). 1

Hospital Admission and Monitoring

Admit to dedicated stroke unit with continuous monitoring for at least 24 hours—stroke unit care reduces mortality and morbidity comparably to alteplase itself. 1, 4

Initial Management

• Keep patient NPO until formal swallowing assessment completed—perform bedside swallowing screen within 24 hours before allowing any oral intake. 4

• Monitor temperature every 4 hours for first 48 hours; treat fever aggressively if >37.5°C (99.5°F) with acetaminophen and cooling measures, as hyperthermia worsens neurological damage. 3, 4

• Begin intermittent pneumatic compression devices within 24 hours for VTE prophylaxis in immobile patients. 1, 4

• Start early mobilization within 24 hours if no contraindications—frequent brief out-of-bed activity involving sitting, standing, and walking. 3, 4

Repeat Imaging

• Repeat non-contrast head CT at 24 hours (or sooner if neurological deterioration) to assess for hemorrhagic transformation, especially if thrombolysis given. 4

Differential Diagnosis Considerations

While stroke is the primary concern, consider:

• Guillain-Barré syndrome if weakness is bilateral, ascending, with areflexia and no sensory level—though this typically presents over days, not acutely. 3

• Seizure with Todd's paralysis—obtain history of witnessed seizure activity. 3

• Hypoglycemia—already ruled out with fingerstick glucose. 1

Critical Pitfalls to Avoid

• Never aggressively lower BP in acute stroke unless giving thrombolytics or BP >220/120 mmHg—permissive hypertension maintains penumbral perfusion. 1

• Never give aspirin within 24 hours of alteplase—this increases hemorrhage risk. 1

• Never delay alteplase for "minor" symptoms—early treatment is critical even for seemingly mild deficits. 1

• Never give oral medications, food, or water before swallowing assessment—aspiration pneumonia significantly worsens outcomes. 4

• Never use vascular imaging to delay treatment in patients within 3-hour window (Class III, Level B). 3