Could a patient presenting with acute unsteadiness, delayed perception of movement, brief falls, transient right‑side weakness, suspected left atrial enlargement with irregular beats, and a normal non‑contrast head CT have experienced a transient ischemic attack (TIA)?

Could This Patient Have Had a TIA (Mini-Stroke)?

Yes, this patient very likely experienced a transient ischemic attack (TIA), and the clinical presentation strongly suggests a cardioembolic mechanism given the transient right-sided weakness resolving within 24 hours, suspected left atrial enlargement, and irregular heartbeats—despite the normal CT/CTV.

Why This is Likely a TIA

The patient meets the classic definition of TIA: acute focal neurological dysfunction (right-sided weakness, balance disturbance, altered perception of movement) that resolved completely within 24 hours 1, 2. Modern definitions emphasize that up to one-third of patients with symptoms lasting <24 hours will have evidence of infarction on MRI even when CT is normal 2. Your patient's normal non-contrast CT does not exclude TIA or even small infarcts—it simply means hemorrhage and large territorial infarcts are ruled out.

Critical Point About Imaging Limitations

Non-contrast head CT has poor sensitivity for:

• Acute ischemic changes in the first 24 hours
• Small cortical or subcortical infarcts
• Posterior circulation strokes
• Lacunar infarcts

The patient needs MRI with diffusion-weighted imaging (DWI), which will detect acute infarction in approximately 30-50% of clinically-defined TIA patients with negative CT 3. This is particularly important because confirming infarction changes risk stratification and secondary prevention strategies.

The Cardiac Connection: High-Risk Features

Your patient has two major red flags for cardioembolic stroke:

1. Suspected left atrial enlargement: Left atrial enlargement is independently associated with increased stroke/TIA risk even without documented atrial fibrillation 4, 5. Severe left atrial enlargement increases ischemic event risk by 75% (HR 1.75) in patients with stroke/TIA 4.

2. Irregular heartbeats ("skipped beat sensations"): This strongly suggests paroxysmal atrial fibrillation, which is frequently asymptomatic and undetected on routine ECG 6, 7.

What You Must Do Next

Immediate cardiac workup is mandatory 2, 8, 9:

1. Extended cardiac monitoring: A single 12-lead ECG is insufficient. The patient needs:

   • Minimum 24-48 hour Holter monitoring initially 8, 9
   • Consider 30-day event recorder or insertable cardiac monitor if initial monitoring is negative—this increases atrial fibrillation detection from 3-5% to 14-16% 3
   • Detection of even brief episodes (≥30 seconds) of atrial fibrillation changes management to anticoagulation

2. Transthoracic echocardiography to:

   • Quantify left atrial size (measure left atrial volume index) 6, 4
   • Assess left atrial function (emptying fraction, strain patterns) 6
   • Exclude structural abnormalities (thrombus, myxoma, valvular disease) 10, 11
   • Evaluate left ventricular function

3. Consider transesophageal echocardiography (TEE) if transthoracic echo is non-diagnostic and suspicion for cardioembolic source remains high—TEE changes management in approximately 1 in 7 patients with embolic stroke of undetermined source 3.

Vascular Imaging: The Missing Piece

Your patient's workup is incomplete without dedicated extracranial and intracranial vascular imaging 12, 8, 9. The CTV showed patent major vessels, but you need:

• CT angiography from aortic arch to vertex (if not already done comprehensively) to evaluate for:
  • Carotid stenosis
  • Intracranial atherosclerosis
  • Vertebrobasilar disease
  • Arterial dissection

The hypoplastic/aplastic right transverse sinus is a normal variant and not the cause of symptoms.

Risk Stratification: This Patient is HIGH RISK

Patients with motor weakness or speech disturbance that resolved within 48 hours are considered highest risk for recurrent stroke, with up to 17% risk of stroke within 90 days and greatest risk in the first week 2, 8, 9. Your patient needs:

• Urgent evaluation within 24 hours of presentation 8, 9
• Immediate initiation of antiplatelet therapy (aspirin 160-325 mg loading dose, then daily) unless contraindicated 13
• Dual antiplatelet therapy (aspirin + clopidogrel) for 21 days if large vessel atherosclerosis is identified and no indication for anticoagulation 13
• Anticoagulation if paroxysmal atrial fibrillation is documented—can be started immediately in TIA patients (unlike moderate-severe strokes where delay is needed) 13

The Vestibular Symptoms: Not Inconsistent with TIA

The balance disturbance, rocking/swaying sensations, and delayed perception of movement could represent:

• Posterior circulation TIA (vertebrobasilar insufficiency affecting vestibular nuclei or cerebellum)
• Cortical involvement affecting sensory integration
• Post-TIA phenomenon (some patients experience persistent non-specific dizziness after TIA)

These symptoms do NOT exclude TIA—in fact, isolated vertigo/imbalance can be the sole manifestation of posterior circulation TIA, though this is less common 8, 9.

Bottom Line: Next Steps

1. Admit or send to rapid-access TIA clinic immediately for comprehensive evaluation 8, 9
2. Start aspirin 160-325 mg now (unless contraindicated)
3. Order MRI brain with DWI urgently (within 24 hours)
4. Arrange extended cardiac monitoring (minimum 24-48 hours, consider 30-day)
5. Obtain transthoracic echocardiography with left atrial measurements
6. Ensure complete vascular imaging (CTA arch-to-vertex if not already done)
7. Aggressive risk factor modification: blood pressure control (target <130/80 mmHg), high-intensity statin, diabetes screening 2

Do not be falsely reassured by the normal CT—this patient had transient focal neurological deficits with cardiac risk factors and requires full TIA workup and urgent secondary prevention to prevent a potentially devastating completed stroke.