Acute Stroke Evaluation and Management

Urgent Assessment and Diagnosis

Patients presenting with unilateral numbness have a 10% risk of completed stroke within the first week, with the highest risk in the first 48 hours, according to the American College of Cardiology 1
The combination of facial numbness with left-sided symptoms has a 72% probability of stroke when accompanied by facial weakness or speech disturbance, as recommended by the American Heart Association 2, 1
Isolated hemibody sensory loss alone still represents high stroke risk, as stated by the American College of Cardiology 1

Check bilateral radial pulses and blood pressure in both arms immediately to differentiate between stroke and acute arterial occlusion, as recommended by the American College of Cardiology 1, 3
A blood pressure difference >20 mmHg between arms confirms significant arterial compromise, according to the American Heart Association 3
Assess the "6 P's" of acute limb ischemia: Pain, Pallor, Pulselessness, Paresthesias (numbness), Poikilothermia (cool limb), Paralysis, as stated by the American College of Cardiology 4, 3
Perform Cincinnati Prehospital Stroke Scale assessment, which includes facial droop, arm drift, and abnormal speech, as recommended by the American Heart Association 2, 1

Brain MRI with diffusion-weighted imaging is the preferred initial imaging modality to detect acute ischemic changes and must be performed immediately, as recommended by the American College of Cardiology 1, 5
MRI differentiates ischemic from hemorrhagic stroke, which fundamentally changes treatment, according to the American Heart Association 1
If MRI is unavailable, perform CT head without contrast to rule out hemorrhage, as stated by the American College of Cardiology 1, 5

Trigeminal neuralgia presents with paroxysmal attacks lasting seconds to minutes with sharp, shooting electric shock-like pain, not continuous numbness for 1 week, as distinguished by the American Academy of Neurology 6
Continuous facial numbness for 1 week is more consistent with stroke, peripheral neuropathy, or structural lesion rather than trigeminal neuralgia, according to the American Academy of Neurology 6

Dual antiplatelet therapy (aspirin + clopidogrel 75 mg) should be initiated for the first 21 days in patients with symptomatic carotid stenosis not undergoing revascularization, followed by long-term single antiplatelet therapy, as recommended by the American College of Cardiology 1
Carotid ultrasound must be performed to identify extracranial carotid stenosis >70% requiring carotid endarterectomy, according to the American Heart Association 1
Immediate vascular surgery consultation for thrombectomy/embolectomy is required as outcome depends entirely on time to reperfusion, as stated by the American College of Cardiology 1, 3