Why sudden one-sided weakness matters
In sudden weakness, time lost is brain lost. Recognise a stroke quickly, exclude mimics such as a low glucose, and get a brain scan fast, because the treatments depend on timing and on whether there is bleeding.
What to ask in the history
- Exactly when she was last seen well, from the witness
- What happened: face, arm, leg, speech, vision
- Headache, vomiting, a seizure at the start
- Previous stroke or mini-stroke
- Irregular heartbeat, blood pressure, diabetes, smoking
- Blood thinners and antiplatelet medicines
- Recent surgery, bleeding or head injury
- How she managed day to day before
Red flags
- Drowsiness
- Severe headache
- Taking blood thinners
- Very high blood pressure
- Symptoms getting worse
- Trouble swallowing
What to examine
- Airway, breathing, circulation; glucose; observations
- Conscious level
- Face, arm and leg power; speech and language; visual fields; eye movements; sensation; neglect
- A structured stroke scale
- Pulse rhythm
- A swallow screen before anything by mouth
First investigations
- Capillary glucose first
- Urgent CT of the brain, with angiography where available
- ECG
- Full blood count, clotting, electrolytes, kidney function
- Later: cholesterol, HbA1c, echocardiogram, carotid imaging
Differential diagnosis of sudden one-sided weakness
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Stroke
- Ischaemic stroke
- Haemorrhagic stroke
Mimics
- Hypoglycaemia
- Weakness after a seizure
- Migraine with aura
- Brain tumour
- Subdural haematoma
- Functional disorder
Infection
- Brain abscess
- Encephalitis
Common mistakes
- Not pinning down when she was last seen well.
- Giving food, drink or tablets by mouth before a swallow check.
- Lowering the blood pressure without a clear reason.