Approach to a 45-Year-Old Male with Right-Sided Weakness (Right UL + LL)

Step 1 - Immediate Assessment (ABC First)

Treat as acute stroke until proven otherwise. Activate stroke team immediately if symptom onset is within 24 hours.

Step 2 - Focused History (FAST Protocol + Details)

Ask:

• Time of onset - exact, or last time known well (LKW)
• Mode of onset - sudden (stroke, hemorrhage) vs. gradual (tumor, abscess, demyelination)
• Associated symptoms:
  • Facial drooping, slurred speech, aphasia
  • Visual changes (hemianopia, diplopia)
  • Headache (severe = hemorrhage, SAH)
  • Seizures
  • Fever (abscess, encephalitis)
  • Neck pain (cervical myelopathy, dissection)
  • Trauma
• Vascular risk factors: HTN, DM, AF, hyperlipidemia, smoking, previous TIA/stroke
• Drug history: anticoagulants, OCP, recreational drugs (cocaine - can cause stroke)
• Family history of stroke, clotting disorders

Step 3 - Neurological Examination

Confirm UMN Pattern:

Key Localizing Signs:

• Cortical signs (aphasia, neglect, cortical sensory loss, homonymous hemianopia) → hemisphere lesion
• Crossed signs (contralateral face palsy + ipsilateral body weakness) → brainstem
• No facial involvement + sensory level → cervical cord (C1-C5)
• NIHSS score - perform to quantify deficit and guide thrombolysis decision

Step 4 - Urgent Investigations

Immediate (Within 10-20 minutes):

Early (Once Stable):

Step 5 - Differential Diagnosis

Step 6 - Management (Stroke Protocol)

If Acute Ischemic Stroke:

• Indicated if onset < 4.5 hours, hemorrhage excluded on CT, no contraindications
• Alteplase: 0.9 mg/kg IV (max 90 mg); 10% as bolus, rest over 60 min
• Admit to Stroke Unit / ICU - reduces mortality and disability

• Consider if large vessel occlusion on CTA (MCA, ICA, basilar)
• Window: up to 24 hours in selected patients

• Keep SBP 160-220 mmHg in acute phase (do NOT aggressively lower BP unless using thrombolytics, where target < 185/110)
• Maintain SpO2 > 94%
• Maintain normoglycemia (target 140-180 mg/dL); avoid hypoglycemia
• Keep head of bed ≥ 30 degrees
• NPO until formal swallowing assessment by speech pathology
• DVT prophylaxis: compression stockings/LMWH once hemorrhage excluded
• Statin therapy early
• Antiplatelets (aspirin 300 mg loading) if hemorrhage excluded and NOT a candidate for thrombolysis

Monitor for Complications:

• Brain edema - peaks 72-120 hours post-stroke; herniation risk in younger patients and large infarcts
• Aspiration pneumonia - occurs in >10% of unilateral hemisphere strokes
• Cardiac arrhythmias - continuous cardiac monitoring ≥ 48 hours
• Urinary retention / infections
• Pressure sores
• Depression - common post-stroke

Step 7 - Rehabilitation

• Physiotherapy - gait training, upper limb exercises
• Occupational therapy - ADL retraining
• Speech and language therapy - if aphasia/dysarthria/dysphagia
• Secondary prevention: antihypertensives, statins, antiplatelet or anticoagulation (if AF), lifestyle modification

Summary Flowchart

Right UL + LL weakness
        ↓
Vitals + Glucose + ECG + IV access + Stroke team
        ↓
Non-contrast CT Brain (< 20 min)
        ↓
Hemorrhage?
  YES → Neurosurgery consult, BP control, Reversal of anticoagulation
  NO  → Is onset < 4.5h? → YES → IV Alteplase (if no contraindications)
                         → Large vessel occlusion? → Thrombectomy
        ↓
Admit to Stroke Unit, supportive care, secondary prevention