Clinical Skills · Supplementary · from Clinical Skills
Case 3: Neurological Examination for Stroke Assessment
Patient Presentation
Demographics: 67-year-old male retired electrician
Chief Complaint: Per wife: "His face is drooping and he can't move his right arm. It started about 45 minutes ago."
History of Present Illness: A 67-year-old right-handed male is brought to the emergency department by EMS after his wife noticed sudden onset of right facial droop, right arm weakness, and difficulty speaking while they were eating breakfast. She reports that at 7:15 AM he was completely normal, and at 7:45 AM (approximately 45 minutes prior to ED arrival) she noticed he dropped his coffee cup with his right hand, his face appeared asymmetric, and his speech became slurred and difficult to understand. She immediately called 911.
EMS reports: Glasgow Coma Scale 13 (E4, V4, M5), Cincinnati Prehospital Stroke Scale positive for all three components (facial droop, arm drift, abnormal speech), blood glucose 142 mg/dL. The patient is within the 4.5-hour window for IV thrombolysis.
A rapid, focused neurological examination is critical for confirming stroke, lateralizing the lesion, calculating the NIH Stroke Scale score, and determining eligibility for acute intervention.
Past Medical History:
- Atrial fibrillation (paroxysmal, diagnosed 2 years ago)
- Hypertension
- Type 2 diabetes mellitus
- Hyperlipidemia
- NOT on anticoagulation (patient declined warfarin 2 years ago; was not offered DOAC)
Medications:
- Aspirin 81 mg daily
- Metformin 500 mg BID
- Amlodipine 10 mg daily
- Atorvastatin 40 mg daily
Social History:
- Retired electrician
- Former smoker (quit 5 years ago, 30 pack-year history)
- Social alcohol (2-3 beers per week)
- Lives with wife in single-story home
- Independent in all ADLs at baseline
Family History:
- Father: stroke at age 74
- Mother: hypertension, alive at 89
Physical Examination
- Vital Signs: BP 178/96 mmHg, HR 88 bpm (irregularly irregular), RR 16/min, Temp 36.9°C, SpO2 96% on room air, Blood glucose 142 mg/dL
- General: Alert but confused elderly male, frustrated by inability to communicate
- Neurological Examination (NIH Stroke Scale):
- 1a. Level of Consciousness: Alert (0)
- 1b. LOC Questions (age, month): Answers one correctly (1)
- 1c. LOC Commands (open/close eyes, grip/release): Performs both correctly (0)
- 2. Best Gaze: Normal horizontal eye movements (0)
- 3. Visual Fields: Right homonymous hemianopia on confrontation testing (2)
- 4. Facial Palsy: Right lower facial droop, unable to show teeth on right; forehead spared bilaterally (indicating UMN pattern) (2)
- 5a. Left Arm Motor: No drift (0)
- 5b. Right Arm Motor: Drifts down within 10 seconds, does not hit bed (2)
- 6a. Left Leg Motor: No drift (0)
- 6b. Right Leg Motor: Drifts down, some effort against gravity (2)
- 7. Limb Ataxia: Unable to assess right side due to weakness; left side normal (0)
- 8. Sensory: Decreased pinprick sensation on right arm and leg (1)
- 9. Best Language: Comprehends simple commands but output is non-fluent, effortful, telegraphic (Broca's aphasia pattern) (2)
- 10. Dysarthria: Moderate slurring, intelligible with effort (1)
- 11. Extinction/Inattention: Right-sided extinction on double simultaneous stimulation (1)
- TOTAL NIHSS: 14 (moderate-severe stroke)
- Additional Neurological Findings:
- Right upper motor neuron facial weakness (lower face only; forehead sparing)
- Right pronator drift
- Right Babinski sign positive (upgoing plantar response)
- Increased tone in right upper extremity
- Right-sided sensory neglect
- Cardiovascular: Irregularly irregular rhythm (atrial fibrillation), no murmurs
- Lungs: Clear bilaterally
Workup and Results
Laboratory Studies:
| Test | Result | Reference Range |
|---|---|---|
| Glucose (point of care) | 142 mg/dL | 70-100 mg/dL |
| INR | 1.0 | 0.9-1.1 |
| PTT | 28 seconds | 25-35 seconds |
| Platelets | 198,000/µL | 150,000-400,000/µL |
| Creatinine | 1.1 mg/dL | 0.7-1.3 mg/dL |
| Troponin I | <0.01 ng/mL | <0.04 ng/mL |
| Hemoglobin | 14.2 g/dL | 13.5-17.5 g/dL |
Imaging/Additional Studies:
- CT Head without contrast (door-to-CT time: 8 minutes): No hemorrhage; no early ischemic changes; ASPECTS score 9/10 (subtle loss of gray-white differentiation in left insular cortex)
- CT Angiogram (head and neck): Occlusion of left middle cerebral artery M1 segment; no significant carotid stenosis; patent circle of Willis otherwise
- CT Perfusion: Large penumbral territory (ischemic but salvageable tissue) in left MCA distribution; core infarct volume 12 mL; mismatch ratio 6.2 (favorable for intervention)
- ECG: Atrial fibrillation with ventricular rate 88 bpm
Clinical Image
Diagram illustrating the key components of the NIH Stroke Scale (NIHSS) neurological examination, showing assessment areas for consciousness, gaze, visual fields, facial palsy, motor function, ataxia, sensory, language, dysarthria, and extinction. Source: Educational illustration.
Diagnosis
Acute Left Middle Cerebral Artery Ischemic Stroke (Cardioembolic, Secondary to Atrial Fibrillation), NIHSS 14
Key Diagnostic Criteria:
- Sudden onset of right-sided weakness, facial droop, and non-fluent aphasia (left MCA territory)
- Upper motor neuron pattern facial weakness (forehead sparing)
- Right homonymous hemianopia (optic radiation involvement)
- Broca's aphasia (left frontal lobe)
- NIHSS 14 indicating moderate-severe deficit
- CT Angiogram confirming left M1 MCA occlusion
- Known atrial fibrillation without anticoagulation (embolic source)
- CHA₂DS₂-VASc score: 5 (AF, age 65-74, HTN, DM, vascular disease history = high stroke risk)
Treatment Plan
- IV alteplase (tPA): 0.9 mg/kg (max 90 mg), 10% as bolus, remainder over 60 minutes -- door-to-needle time goal <45 minutes
- Mechanical thrombectomy: Given large vessel occlusion (M1 MCA) with favorable perfusion imaging (large penumbra, small core), proceed to endovascular thrombectomy -- door-to-groin puncture goal <90 minutes
- Blood pressure management: Permissive hypertension up to 185/110 pre-tPA; post-tPA maintain <180/105 for 24 hours with IV labetalol or nicardipine infusion
- Admit to Neuro ICU/Stroke Unit: Continuous cardiac monitoring, neuro checks every 15 minutes for first 2 hours, then hourly; NPO until swallowing assessment
- Anticoagulation: Initiate DOAC (apixaban 5 mg BID) after 24-hour follow-up imaging confirms no hemorrhagic conversion; indefinite anticoagulation for AF (CHA₂DS₂-VASc 5)
- Secondary prevention: High-intensity statin, blood pressure optimization, glucose management
- Rehabilitation: Early PT/OT/Speech therapy assessment within 24 hours; discharge planning for inpatient rehabilitation
Key Learning Points
- The NIH Stroke Scale is a standardized, reproducible neurological assessment that quantifies stroke severity and guides treatment decisions (NIHSS ≥6 with LVO is a strong indicator for thrombectomy evaluation)
- Upper motor neuron (UMN) facial weakness spares the forehead because the upper face receives bilateral cortical innervation, while lower face receives only contralateral innervation
- Localization of stroke deficits to vascular territories is a fundamental clinical skill: right hemiparesis + right facial droop + Broca's aphasia + right hemianopia = left MCA territory
- The time-critical nature of stroke care requires a rapid, focused neurological examination; the NIHSS can be performed in under 7 minutes by trained examiners
- Atrial fibrillation is the most common cause of cardioembolic stroke; this case illustrates the consequence of inadequate anticoagulation (CHA₂DS₂-VASc score of 5 carries an annual stroke risk of approximately 6.7%)