John Bielinski, MS PA-C 
To image or not image – that is the question!
This was a dilemma for me. Well, not at first. This was a simple clinical diagnosis. Bell’s involved the forehead. CVA did not. Bell’s is viral. CVA is clot. Bell’s can go home. CVA, not so much.
Bell’s palsy versus CVA: A breakdown
The pathology of Bell’s is damage to the facial nerve. The damage (we think) occurs from inflammation to the nerve from the skull – probably due to a viral infection. Prompt treatment with anti-virals or steroids do well.
A stroke, usually thromboembolic, is from a clot. When facial weakness is involved in a stroke, it almost always affects only those muscles below the eye (such as the mouth and cheeks) and not the eye or forehead.
So, as clinical providers, what are we to do when presented with a clear presentation of Bell’s?
If you are a PA or NP, this situation can be a medical legal hot bed. I recommend having a discussion. There is a perception that needs to be met. Between the patient, the hospital and the physician you are working with.
The standard of care is that Bell’s is a clinical diagnosis. If it’s a classic Bell’s, then there is no imaging needed. If there is any concern by way of presentation, risk factors or the NIH stroke scale physical findings, that is a different story and demands appropriate work up.
I address decisions like this and other situations that can arise in our emergency medicine CME. I invite you to check it out and share your feedback!
