Ischemic Stroke vs Bell Palsy
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.
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Side-by-side comparison
| Feature | Ischemic Stroke | Bell Palsy |
|---|---|---|
| At a glance | Acute focal neurologic deficit from arterial occlusion causing brain infarction. | Acute idiopathic peripheral CN VII palsy with unilateral facial weakness involving the forehead. |
| Classic presentation | Sudden 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 labs | Clinical syndrome of acute focal neurologic deficit with imaging evidence of infarction (CT hypodensity or MRI DWI restriction) and exclusion of hemorrhage.; Fingerstick glucose immediately (rule out hypoglycemia); CBC, platelets, PT/INR, PTT, BMP, troponin; Lipid panel, A1c — for secondary prevention; Pregnancy test in women of… | 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… |
| Imaging | Non-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 treatment | tPA 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); Tenecteplase 0.25 mg/kg IV bolus — increasingly used alternative, particularly with LVO bridging to thrombectomy; Mechanical thrombectomy for anterior… | 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… |
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