Confusable diagnoses · PANCE / PANRE

Ischemic Stroke vs Bell Palsy

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

Ischemic Stroke and Bell Palsy are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.

Ischemic Stroke vs Bell Palsy at a glance

  • Ischemic Stroke: Acute focal neurologic deficit from arterial occlusion causing brain infarction.
  • Bell Palsy: Acute idiopathic peripheral CN VII palsy with unilateral facial weakness involving the forehead.

Try two board-style questions on Ischemic Stroke vs Bell Palsy

Real questions from the FirstPassPA bank, with the full explanation. Pick an answer — no signup, no email.

Question 1NeurologyEasy
A 65-year-old female has an acute right hemisphere ischemic stroke with left-sided weakness and left-sided neglect. She arrives at the ED 2.5 hours after symptom onset. National Institutes of Health Stroke Scale (NIHSS) is 14. CT shows no hemorrhage and no large territory infarct. She has no contraindications. Which of the following treatments is most appropriate?
  • AIV heparin infusion
  • BAspirin 325 mg orally immediately
  • CIV alteplase 0.9 mg/kg
  • DAspirin plus clopidogrel loading dose
Reveal answer & full explanation
Correct answer: C — IV alteplase 0.9 mg/kg
  • AIV heparin infusion
  • BAspirin 325 mg orally immediately
  • CIV alteplase 0.9 mg/kg✓
  • DAspirin plus clopidogrel loading dose

Why IV alteplase 0.9 mg/kg is correct

  • IV alteplase 0.9 mg/kg given within 4.5 hours of symptom onset reduces 90-day disability (modified Rankin scale) by 30%.
  • This patient arrived at 2.5 hours with no hemorrhage on CT, no large territory infarct, NIHSS of 14, and no stated contraindications — all criteria are met.

Why the others are wrong

  • IV heparin infusion — IV heparin is not indicated for acute ischemic stroke and increases bleeding risk without proven benefit (right-concept-wrong-drug).
  • Aspirin 325 mg orally immediately — aspirin is started 24 hours after tPA, not before, to avoid compounding hemorrhagic risk (wrong-timing).
  • Aspirin plus clopidogrel loading dose — dual antiplatelet therapy is used for high-risk TIA or minor ischemic stroke (POINT/CHANCE trials), not as a substitute for thrombolysis in a patient eligible for alteplase (confused-with minor-stroke protocol).

Additional high-yield points

  • Time is brain: 1.9 million neurons are lost per minute of ischemia.
  • Absolute contraindications to alteplase include hemorrhage on CT, prior intracerebral hemorrhage (ICH), systolic blood pressure (SBP) above 185 or diastolic blood pressure (DBP) above 110, platelets below 100K, anticoagulants with therapeutic INR above 1.7, and active bleeding.
  • Mechanical thrombectomy (MT) is indicated for large vessel occlusion (LVO) involving the internal carotid artery (ICA), M1, or basilar artery, with NIHSS above 6, within 24 hours (extended window with perfusion imaging per DAWN/DEFUSE-3 trials); MT plus tissue plasminogen activator (tPA) is superior to tPA alone for LVO.
  • Tenecteplase 0.25 mg/kg IV bolus is non-inferior to alteplase, simpler to administer as a single bolus, and increasingly used.
Question 2NeurologyMedium
A 31-year-old woman who is 34 weeks pregnant and has gestational diabetes reports that the right side of her face suddenly drooped overnight. She cannot raise her right eyebrow, close her right eye completely, or smile on the right, and food collects in her right cheek. There is no limb weakness, no rash, and the remainder of the neurologic exam is normal. She had a mild upper respiratory illness the week before. Which of the following is the most likely diagnosis?
  • AIdiopathic Bell palsy
  • BAcute ischemic stroke
  • CRamsay Hunt syndrome
  • DFacial nerve schwannoma
Reveal answer & full explanation
Correct answer: A — Idiopathic Bell palsy
  • AIdiopathic Bell palsy✓
  • BAcute ischemic stroke
  • CRamsay Hunt syndrome
  • DFacial nerve schwannoma

Why Idiopathic Bell palsy is correct

  • This is Bell palsy -- acute idiopathic lower-motor-neuron facial nerve (CN VII) palsy.
  • Pregnancy (especially the third trimester and peripartum period) and diabetes are the two best-established risk factors; both promote facial-nerve edema and ischemia within the bony facial canal, often after a viral or inflammatory trigger, and incidence is roughly threefold higher in pregnant patients.
  • The hallmark that localizes the lesion to the peripheral nerve rather than the brain is involvement of the ENTIRE half of the face, including the forehead (she cannot raise the eyebrow or close the eye).

Why the others are wrong

  • Acute ischemic stroke — an upper-motor-neuron facial weakness SPARES the forehead because of bilateral cortical innervation of the upper face, and it usually comes with other focal deficits; her forehead involvement and otherwise normal exam argue against stroke.
  • Ramsay Hunt syndrome — is herpes-zoster reactivation causing facial palsy WITH a painful vesicular rash in the ear canal and severe otalgia, none of which are present.
  • Facial nerve schwannoma — causes a slowly progressive, not overnight, facial palsy and often hearing loss; the abrupt onset here fits idiopathic Bell palsy.
🔒 Free preview limit reached

Keep comparing — start your free trial

You've used your 2 free previews. Create your free account to see the full Ischemic Stroke vs Bell Palsy comparison — plus all 514 diagnosis outlines, 7,200+ board-style questions, and an AI tutor. Your 7-day free trial includes everything, no credit card required.

Start your 7-day free trial → Sign in
Free to start · No credit card · Cancel anytime

Side-by-side comparison

FeatureIschemic StrokeBell Palsy
At a glanceAcute focal neurologic deficit from arterial occlusion causing brain infarction.Acute idiopathic peripheral CN VII palsy with unilateral facial weakness involving the forehead.
Classic presentationSudden onset focal deficit referable to a single vascular territory; NIHSS quantifies severity (0-42).; Sudden, focal neurologic deficit: unilateral weakness, sensory loss, aphasia, dysarthria, gaze deviation, hemianopia, ataxia, vertigo; Symptoms maximal at onset (contrast with progressive course of tumor); Headache uncommon (more…Unilateral LMN facial palsy involving the forehead — if forehead is spared, think central (stroke) lesion.; Acute onset over hours; maximal weakness within 72 hours; Unilateral facial weakness/paralysis affecting BOTH upper and lower face (cannot raise eyebrow, close eye, smile symmetrically); Inability to close affected eye → dry eye,…
Workup / key labsClinical syndrome of acute focal neurologic deficit with hemorrhage excluded on non-contrast CT (often normal in the first hours); infarction is confirmed by MRI DWI restriction or later CT hypodensity, or by a deficit persisting >24 h.; Fingerstick glucose immediately (rule out hypoglycemia); CBC, platelets, PT/INR, PTT, BMP, troponin;…Clinical diagnosis of acute peripheral LMN facial weakness in the absence of identifiable cause. Onset over <72 hours, no other cranial nerve involvement, no signs of central or otologic pathology.; Usually none required — clinical diagnosis; Consider: Lyme serology in endemic areas; HIV testing if risk factors; A1c if undiagnosed…
ImagingNon-contrast head CT within 20 min of arrival — excludes hemorrhage (essential before tPA); CT angiography head and neck — identifies large vessel occlusion candidates for thrombectomy; CT perfusion or MR diffusion/perfusion — quantifies core vs penumbra for extended-window thrombectomy (DAWN, DEFUSE-3); MRI with DWI — most sensitive…Not routinely indicated for typical presentation; MRI brain with contrast if: atypical features (slow onset >72 h, gradual progression beyond 3 weeks, no recovery by 3-4 months, other cranial nerves involved, recurrence, bilateral, mass found) → exclude tumor (schwannoma, parotid), stroke, demyelinating disease; CT temporal bone if…
First-line treatmenttPA dosing — alteplase 0.9 mg/kg IV (max 90 mg), 10% as bolus over 1 min, remainder over 60 min, if within 4.5 h of last known well and no contraindications (NINDS, ECASS III); 4.5-9 h from last known well or wake-up stroke only if automated perfusion imaging shows salvageable penumbra (EXTEND; AHA/ASA 2026); mild nondisabling deficits…Corticosteroids — high-dose oral prednisone 60 mg/day x 5 days, then taper over 5 days (or prednisolone equivalent), started within 72 hours of symptom onset for best benefit (improves complete recovery rate; SCANDINAVIAN BELL trial, Sullivan trial); Eye protection (essential to prevent exposure keratopathy): artificial tears every 1-2…

Drill Ischemic Stroke vs Bell Palsy questions on FirstPassPA

Turn this comparison into retention. 7,200+ board-style questions with an AI tutor that explains every answer — free to start, no card required.

Answer the 2 free questions above → Get today's free question →

Full outlines

Ischemic Stroke Bell Palsy All 514 diagnoses

Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.