CVA?

[tyson]

So let me present a case and see if you guys would have done anything different. 

52 year old female, pmh of DM2, HTN, HLD and remote hx of TIA's presents to ED with left side facial droop. states that night before, started developing a headache, and some numbness and tingling on left side, but went to bed. Woke up with left sided facial droop and slurred speech. States her left arm felt weak as well. PE: patient able to raise eyebrows, difficulty closing left eye and visible left side facial droop. speech slightly slurred. NIHSS otherwise normal. I believe I graded it a 2-3. 

My impression initially was this was likely a weird bells palsy with the tingling at tip of tongue, inability to close eyes and otherwise normal neurological exam. However, w/ her pmh history, complaints of left arm weakness, ability to raise eyebrows and no flattening of forehead, couldn't exclude a central vs peripheral cause. 

I shipped her to TTH for neurological examination. 
Hospitalist graded her NIHSS at 2. Thought she possibly had CVA. 
Neuro consult graded NIHSS at 3, and MRI, ECHO, Carotid showed essentially normal exam. She was discharged on steroids. 

Is there any way you guys with her history and exam could have definitively called this a Bells? That's where my money was, but didn't have anywhere near certainty to d/c home on steroids. 

Anything you'd do different? 

Tyson

[jpollock]

slurred speech & subjective arm weakness makes it easy. We all get cases where we feel its overkill, but this patient made it easy for you to call it a CVA/TIA and let neuro make the final call. There are a lot of atypical migraines, bells, Saturday night palsy, etc that we end up calling as strokes that really aren't, but since I don't want to miss one, I ship them and get the consult.

Specifically with Bell's palsy: either its classic or its a neuro consult. in your case, there are several things that while not impossible with bells are certainly atypical. no shame in what you did

[erinto]

When in doubt, always go with the conservative route. It might be Bell's, but you will cause no harm by treating as a CVA. Would I give tPA? No, probably not on this one, even if the window was clear, unless I was really convinced it was a CVA, and only if neuro agreed.