31 years female with no known comorbidity came with history of right sided parapersis since today morning bp was 120/80 pulse 80 beats per mins power 4/5 in right side planter evivocal
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Clinical Assessment
Patient Summary
31-year-old female | No known comorbidities | Acute onset right-sided weakness this morning
- BP: 120/80 mmHg | Pulse: 80 bpm
- Power: 4/5 right side (upper motor neuron pattern)
- Plantar: Equivocal (Babinski sign — suggests UMN pathology)
Most Likely Diagnosis: Acute Left Hemisphere Ischemic Stroke
The abrupt onset of a focal neurologic deficit in the distribution of a specific vascular territory is the hallmark of acute ischemic stroke. The right hemiparesis with equivocal plantar response points to a left hemisphere/corticospinal tract lesion. In a young woman with no comorbidities, this is a stroke-until-proven-otherwise presentation.
"The abrupt onset of a focal neurologic deficit in the distribution of a specific vascular territory is the hallmark of acute ischemic stroke." — Goldman-Cecil Medicine
Localisation
| Finding | Implication |
|---|---|
| Right-sided weakness (hemiparesis) | Left hemisphere or left corticospinal tract |
| Equivocal plantar (upgoing toe) | Upper motor neuron lesion — cortex/subcortex/internal capsule |
| Power 4/5 (partial deficit) | Incomplete MCA territory or small vessel/lacunar infarct |
| Normal BP (120/80) | Against hypertensive ICH; favors ischemic etiology |
Most likely vascular territory: Left MCA (middle cerebral artery) — especially the posterior limb of the internal capsule if pure motor hemiparesis.
Differential Diagnosis in a Young Woman
Given she is 31 with no comorbidities, always consider unusual stroke causes:
| Cause | Key Notes |
|---|---|
| Cardioembolic stroke | Patent foramen ovale (PFO), atrial septal defect, valvular disease (rheumatic MS) |
| Antiphospholipid antibody syndrome (APS) | Young woman, may have history of recurrent miscarriages or DVT |
| Oral contraceptive use | Estrogen-containing pills → hypercoagulable state |
| Cerebral venous sinus thrombosis (CVST) | Young women; headache + focal deficits; often peripartum or OCP-related |
| Cervical artery dissection | Neck pain/trauma history; carotid or vertebral artery dissection |
| Vasculitis / CNS vasculitis | Can present with headache + multiple infarcts |
| Migrainous infarction | Hemiplegic migraine — must exclude; rare, diagnosis of exclusion |
| Coagulopathy | Factor V Leiden, protein C/S deficiency, prothrombin mutation |
| CADASIL / genetic stroke syndromes | Rare, usually with family history |
| Demyelination (MS) | Can mimic stroke; check MRI for plaques |
| Todd's paralysis | Post-ictal hemiparesis; needs seizure history |
| Space-occupying lesion | Tumor/abscess (subacute onset, but can appear acute) |
Coagulation disorders and antiphospholipid syndrome are more commonly associated with stroke in young people with unknown cause or history of late miscarriages/unprovoked DVT. — Goldman-Cecil Medicine
Immediate Management (Time-Critical)
Step 1 — Stabilise & Assess
- Airway, Breathing, Circulation
- IV access, oxygen (target SpO₂ > 94%)
- Continuous cardiac monitoring (12-lead ECG — rule out AF)
- Blood glucose immediately (hypoglycemia mimics stroke)
- Check last known well time — thrombolysis window is critical
Step 2 — Urgent Investigations
Immediate (all patients):
| Investigation | Reason |
|---|---|
| Non-contrast CT brain | Rule out hemorrhage before thrombolysis |
| MRI brain + DWI/ADC | Gold standard — shows ischemia within minutes |
| CT/MR angiography | Detect large vessel occlusion (LVO) for thrombectomy |
| CBP + platelets | Exclude thrombocytopenia |
| PT/INR, aPTT | Coagulation status |
| Blood glucose | Exclude hypoglycemia |
| Serum electrolytes, renal function | Baseline |
| Troponin | Cardiac injury |
| ECG | Detect AF or arrhythmia |
| SpO₂ | Oxygenation |
In this young woman — add:
| Investigation | Reason |
|---|---|
| Echocardiogram (TTE/TEE) | PFO, valvular disease, intracardiac thrombus |
| Thrombophilia screen | Protein C, S, antithrombin III, Factor V Leiden, prothrombin gene mutation |
| Antiphospholipid antibodies | Anticardiolipin IgG/IgM, lupus anticoagulant, anti-β2GPI |
| ANA, anti-dsDNA | Screen for SLE/vasculitis |
| Carotid Doppler/CTA neck | Cervical dissection |
| Urine pregnancy test | If LMP uncertain |
| OCP / hormonal contraceptive use | History |
| Lipid profile, HbA1c | Metabolic risk factors |
| Holter monitor / prolonged cardiac monitoring | Paroxysmal AF |
Thrombolysis Decision
Time is brain. If symptoms onset was this morning and patient presents within 4.5 hours, evaluate for IV alteplase (tPA):
Inclusion:
- Diagnosis of ischemic stroke with measurable neurological deficit
- Onset < 3 hours (or up to 4.5 hours with additional criteria)
- Age ≥ 18
Assess for exclusions (e.g., recent surgery, bleeding history, anticoagulant use, BP > 185/110, blood glucose < 50 or > 400).
If large vessel occlusion (LVO) on CTA → urgent mechanical thrombectomy within 24 hours of symptom onset (if eligible).
Key Clinical Points
- Ask about OCP use — estrogen-containing contraceptives are a significant stroke risk factor in young women.
- Ask about headache onset — sudden severe headache suggests SAH or CVST.
- Ask about neck pain/recent trauma — carotid/vertebral dissection.
- Ask about miscarriage history / prior DVT — antiphospholipid syndrome.
- NIHSS scoring should be performed immediately to document deficit severity and guide treatment.
- Admit to stroke unit — organized inpatient multidisciplinary care reduces mortality and disability by ~30-35%.
Summary Algorithm
31F + acute right hemiparesis + UMN signs
↓
Immediate: Glucose check + CT brain (exclude hemorrhage)
↓
Hemorrhage? → Neurosurgery
No hemorrhage → Ischemic stroke pathway
↓
Time from onset < 4.5 hrs → Consider IV tPA
LVO on CTA → Mechanical thrombectomy
↓
Young woman workup: Echo, APS screen, thrombophilia,
dissection imaging, OCP history, vasculitis screen
The most important immediate next step is non-contrast CT brain to exclude hemorrhage, followed by MRI with DWI to confirm ischemia and guide treatment — Goldman-Cecil Medicine, Chapter 376.
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