How should a normotensive, awake, alert patient with sudden left upper extremity numbness and weakness be evaluated and managed?

Acute Stroke Evaluation and Management

Immediate Action Required

This patient requires immediate emergency medical services activation and transfer to a comprehensive stroke center with advanced imaging and thrombolysis capabilities within minutes. 1

Sudden onset unilateral numbness and weakness of the left upper extremity in an awake, alert patient represents a high-risk presentation for acute ischemic stroke affecting the right cerebral hemisphere, specifically the right middle cerebral artery territory. 1

Critical Time-Sensitive Steps

Within First 5-10 Minutes

• Activate stroke code immediately - patients presenting within 48 hours of unilateral weakness are considered highest risk and require same-day assessment at the closest stroke center with advanced stroke care capacity 1

• Establish exact time of symptom onset or last known normal time - this determines eligibility for IV thrombolysis (3-4.5 hour window) and endovascular thrombectomy 1

• Perform bedside glucose check immediately - hypoglycemia is a critical stroke mimic that must be excluded before further workup 1

• Assess using standardized stroke scale - perform National Institutes of Health Stroke Scale (NIHSS) to quantify neurological deficits, facilitate communication, identify vessel occlusion location, and determine intervention eligibility 1

Blood Pressure Management

Do not treat the normal blood pressure in this patient. 2, 3

• Blood pressure should only be lowered if systolic BP >220 mmHg or diastolic BP >120 mmHg in non-thrombolysis candidates 2, 3

• If thrombolysis is planned, BP must be reduced to <185/110 mmHg before infusion and maintained <180/105 mmHg afterward to limit hemorrhage risk 2, 3

• Elevated BP in acute stroke represents a physiological response to maintain cerebral perfusion in ischemic tissue - aggressive lowering can worsen outcomes 2, 3

Urgent Diagnostic Workup (Within 30-60 Minutes of Arrival)

Neuroimaging Priority

Non-contrast CT head is the minimum required imaging to exclude intracranial hemorrhage before thrombolysis. 1

• CT angiography from aortic arch to vertex should be performed simultaneously to identify large vessel occlusion requiring endovascular thrombectomy and assess both extracranial and intracranial circulation 1

• CTA allows visualization of the intracranial circulation, posterior circulation, and aortic arch to identify stroke etiology and guide management decisions 1

Laboratory Investigations

Obtain immediately: 1

• Complete blood count
• Electrolytes and renal function (creatinine, eGFR)
• Coagulation studies (aPTT, INR) - essential for thrombolysis eligibility 1
• Capillary glucose level (already done at bedside)

Cardiac Evaluation

• 12-lead ECG to assess baseline cardiac rhythm and identify atrial fibrillation or other cardioembolic sources 1

Treatment Decisions Based on Imaging

If Ischemic Stroke Confirmed Without Hemorrhage

IV thrombolysis (rtPA) should be administered if within 3-4.5 hours of symptom onset and no contraindications exist. 1, 4

Endovascular thrombectomy should be pursued if large vessel occlusion identified on CTA, even beyond the IV thrombolysis window. 1, 4

If Hemorrhage Identified

• Immediate neurosurgical consultation 1
• Blood pressure targets become more aggressive - consider lowering systolic BP to 140 mmHg as rapid BP reduction is generally well tolerated in intracerebral hemorrhage without risk of neurological worsening 2
• Reverse any coagulopathy immediately 1

Critical Pitfalls to Avoid

• Do not delay transfer for extensive workup - time is brain tissue, and every minute of delay worsens outcomes 1, 4

• Do not aggressively lower normal or mildly elevated blood pressure - cerebral perfusion in ischemic tissue depends on elevated BP, and lowering it can extend the infarct 2, 3

• Do not assume atypical presentations are not stroke - while isolated sensory symptoms without motor weakness may be lower risk, this patient has both numbness AND weakness, placing them in the highest risk category 1

Ongoing Monitoring (First 24-48 Hours)

• Neurological assessments using validated scales (NIHSS or Canadian Neurological Scale) should be performed at baseline and repeated at least hourly for the first 24 hours 1

• Blood pressure monitoring every 15 minutes until stabilized, then every 30-60 minutes for at least 24-48 hours 1

• Continuous cardiac monitoring to detect paroxysmal atrial fibrillation 1