From the Guidelines
The workup for this 47-year-old female with left-sided facial and arm tingling should focus on ruling out a recurrent stroke or transient ischemic attack (TIA), and I recommend an immediate neurological evaluation including brain imaging with CT or MRI, carotid ultrasound, and ECG, as suggested by the most recent guidelines 1. The patient's symptoms, including tingling sensation in the left side of her face and left arm, along with her history of possible stroke and current neck pain, warrant a thorough evaluation to determine the underlying cause. The differential diagnosis includes:
- Recurrent stroke/TIA
- Cervical radiculopathy
- Multiple sclerosis
- Migraine with aura
- Peripheral neuropathy Given her recent possible stroke and current symptoms, she should be evaluated in an emergency setting. Laboratory tests should include:
- Complete blood count
- Coagulation studies
- Lipid panel
- Blood glucose The patient is already on Plavix (clopidogrel) for secondary stroke prevention, which is appropriate, but medication compliance and effectiveness should be assessed, as supported by the guidelines 1. If stroke is confirmed, she may need additional antiplatelet therapy or anticoagulation depending on the etiology, and blood pressure management is crucial, as recommended by the guidelines 1. Lifestyle modifications including smoking cessation, diet changes, and exercise should be discussed, and the neurological symptoms affecting one side of the body, combined with her stroke history, strongly suggest a cerebrovascular etiology, though the neck pain raises the possibility of a cervical spine issue contributing to or mimicking stroke symptoms. Cervical spine imaging is warranted to rule out any cervical spine involvement, as suggested by the guidelines 1. Overall, the goal of the workup is to determine the underlying cause of the patient's symptoms and to provide appropriate treatment to prevent further stroke or TIA, as recommended by the most recent guidelines 1.
From the Research
Workup for the Patient
The patient's symptoms of tingling sensation in the left side of her face and left arm, along with a history of possible stroke and current medication with Plavix, require a thorough workup. The following steps should be taken:
- Immediate imaging of the brain and intracranial and extracranial blood vessels using CT, CT angiography, carotid Doppler ultrasound, and MRI to rule out any acute ischemic stroke or transient ischemic attack (TIA) 2, 3
- Evaluation of the patient's vascular risk factors, such as blood pressure, diabetes, and hyperlipidemia 2, 3
- Assessment of the patient's current medication regimen, including the use of Plavix, and consideration of dual antiplatelet therapy with aspirin and clopidogrel if indicated 3
Differential Diagnosis
The patient's symptoms could be indicative of several conditions, including:
- Transient ischemic attack (TIA) 2, 4, 3
- Acute ischemic stroke (AIS) 3, 5
- Carotid artery stenosis 2, 3
- Atrial fibrillation 2, 3
- Other conditions that may mimic TIA or AIS, such as migraines or seizures 2
Evaluation and Management
The patient's evaluation and management should be guided by the results of the workup and the differential diagnosis. The following considerations should be taken into account:
- The patient's history of possible stroke and current symptoms suggest a high risk of recurrent stroke, and urgent assessment and treatment are necessary to prevent further stroke 2, 4
- The use of dual antiplatelet therapy with aspirin and clopidogrel may be indicated to reduce the risk of stroke in patients with high-risk TIA or minor stroke 3
- Carotid revascularization and single antiplatelet therapy may be indicated for patients with symptomatic carotid stenosis 3
- Anticoagulation may be indicated for patients with atrial fibrillation 2, 3
- Mechanical thrombectomy may be indicated for patients with disabling AIS due to anterior circulation large-vessel occlusions 3