What is the appropriate emergency evaluation and initial management for a patient who presents with a facial expression of tension (face drawn up) and bilateral arm paresthesias?

Emergency Evaluation and Management of Facial Tension with Bilateral Arm Paresthesias

Immediate Priority: Rule Out Acute Stroke

This presentation requires immediate emergency evaluation for acute ischemic stroke, particularly posterior circulation (vertebrobasilar) involvement, as bilateral symptoms with facial involvement suggest brainstem pathology that carries high mortality risk and requires urgent neuroimaging and potential thrombolytic therapy within minutes to hours. 1, 2

Critical Distinguishing Features

The combination of facial symptoms with bilateral arm involvement is atypical for typical anterior circulation stroke and raises specific diagnostic considerations:

Most Likely Life-Threatening Diagnoses

• Basilar artery territory stroke affecting bilateral descending motor tracts can cause bilateral arm weakness with facial involvement 2
• Multiple embolic events in rapid succession affecting both hemispheres 2
• Progressive thrombotic stroke with bilateral motor pathway involvement 2
• Patients with unilateral weakness progressing to bilateral involvement have up to 10% risk of recurrent stroke within the first week, with highest risk in the first 48 hours 1, 2

Alternative Neurological Emergencies

• Guillain-Barré Syndrome (GBS) can present atypically with arm-predominant or simultaneous limb involvement, though classically ascending from legs 2
• GBS is characterized by bilateral relatively symmetric weakness, decreased or absent reflexes, and preceding infection history 2
• Acute cervical myelopathy at C5-T1 level can cause bilateral arm weakness 2

Immediate Actions Required (Within Minutes)

1. Activate Emergency Medical Services

• Only 53% of stroke patients currently use EMS despite clear mortality benefit 1, 2
• Transfer to emergency department with advanced stroke capabilities including on-site brain imaging, IV tPA access, and endovascular thrombectomy capability 2, 3

2. Establish Time Zero

• Document exact time of symptom onset or last known normal time to determine eligibility for IV tPA (within 4.5 hours) or endovascular thrombectomy (up to 24 hours for select patients) 2, 3

3. Bedside Glucose Testing

• Hypoglycemia must be ruled out immediately as it can cause focal neurological deficits mimicking stroke 1, 2
• This is a common and easily correctable stroke mimic 4, 5

4. Focused Neurological Examination

• Assess all cranial nerves to detect brainstem involvement 6
• Check for ataxia, cranial nerve deficits, visual field loss, dizziness, imbalance, and incoordination suggesting vertebrobasilar involvement 6
• Examine deep tendon reflexes: preserved/normal reflexes suggest stroke, while decreased/absent reflexes suggest GBS 2
• Document using standardized scale (NIHSS) for communication and treatment decisions 6

5. Key Historical Elements

• Sudden versus gradual onset: abrupt onset is hallmark of stroke 4, 7
• Preceding infection history suggests GBS 2
• Witnessed seizure activity suggests postictal state 6, 5
• History of neck trauma or manipulation suggests cervical myelopathy 2
• Vascular risk factors (hypertension, smoking, diabetes, atrial fibrillation) increase stroke likelihood 3, 8

Urgent Diagnostic Workup (Within 20-45 Minutes of Arrival)

Neuroimaging Priority

• Non-contrast CT head is minimum required to exclude intracranial hemorrhage before thrombolysis 3
• CT angiography from aortic arch to vertex should be performed within 24 hours to identify large vessel occlusion requiring endovascular thrombectomy 1, 3
• Do NOT delay imaging for laboratory results—brain imaging takes priority over all other testing 1

Additional Testing

• Electrocardiogram to assess for atrial fibrillation or acute cardiac event 1
• Complete blood count, serum electrolytes, creatinine 1
• Coagulation studies if anticoagulation or thrombolysis considered 6

Critical Pitfalls to Avoid

• Do not assume symptoms are "too mild" to be stroke—even transient symptoms carry 10% risk of completed stroke within one week 1
• Do not treat hypertension aggressively in acute stroke unless BP >185/110 mmHg for tPA candidates or >220/120 mmHg otherwise, as cerebral perfusion depends on elevated BP 3
• Do not delay care to obtain extensive vascular imaging—non-contrast CT is sufficient to initiate thrombolysis 3
• Do not miss stroke mimics but recognize that stroke mimics treated with tPA have not shown increased hemorrhage risk 6

Distinguishing Stroke from GBS

Feature	Stroke	Guillain-Barré Syndrome
Onset	Sudden (seconds to minutes) [4,7]	Acute/subacute (hours to days) [2]
Pattern	Contralateral deficits from unilateral lesion OR bilateral with basilar involvement [2]	Bilateral relatively symmetric weakness [2]
Reflexes	Preserved or normal initially [2]	Decreased or absent [2]
Preceding illness	Vascular risk factors [3]	Recent infection history [2]

Time-Critical Treatment Considerations

• Every minute counts: "time is brain" in acute stroke treatment 3
• IV tPA eligibility window is 4.5 hours from symptom onset 3
• Endovascular thrombectomy can be performed up to 24 hours in select patients with large vessel occlusion 3
• Early recognition and treatment are critical for mortality and morbidity reduction 3