What is the next step in management for a patient with Transient Ischemic Attack (TIA) presenting with left-sided body weakness and left-face weakness?

Management of TIA with Left-sided Body and Face Weakness

For a patient with TIA presenting with left-sided body weakness and left-face weakness, urgent brain imaging with CT should be performed immediately as the next step in management. 1, 2

Risk Assessment and Rationale

This patient presents with symptoms that classify them as VERY HIGH risk for recurrent stroke:

• Left-sided body weakness
• Left-sided face weakness

These symptoms indicate:

• Possible right hemispheric TIA (likely involving the right internal carotid artery or middle cerebral artery territory) 1
• High risk of early recurrent stroke (up to 10% within the first week) 1

Management Algorithm

1. Immediate Brain Imaging (CT)

   • Must be completed as soon as possible within 24 hours 1
   • CT is the first-line imaging choice in the emergency setting to:
     • Rule out hemorrhage
     • Identify early signs of infarction
     • Guide further management decisions

2. After Initial CT

   • Non-invasive vascular imaging (CTA or MRA from aortic arch to vertex)
   • ECG should be completed without delay 1
   • Complete blood work including CBC, coagulation studies, electrolytes, and renal function tests 2

3. Subsequent Management

   • Initiate antiplatelet therapy (aspirin, clopidogrel, or aspirin-dipyridamole) if no contraindications exist and hemorrhage has been ruled out 2
   • Consider high-intensity statin therapy regardless of baseline cholesterol levels 2
   • Blood pressure management (target <140/90 mmHg) while avoiding excessive lowering in the first few days 2

Why CT First (Option B) is Correct

CT is the correct next step because:

• It rapidly excludes hemorrhage which would contraindicate antiplatelet therapy
• The Canadian Stroke Best Practice Recommendations explicitly state that urgent brain imaging should be completed "as soon as possible" for patients with high-risk TIA symptoms 1
• It allows for proper risk stratification and guides subsequent management decisions

Why Other Options Are Not Appropriate First Steps

• Aspirin (Option A): While antiplatelet therapy is important, it should only be initiated after hemorrhage has been ruled out by neuroimaging 2
• Brain MRI (Option C): While MRI provides more detailed information, it takes longer to obtain and may delay treatment. CT is more readily available and sufficient for initial assessment in the emergency setting 1, 2

Important Considerations

• Time is critical - the highest risk of recurrent stroke is within the first 48 hours after TIA 1, 2
• Left-sided weakness indicates involvement of the right hemisphere, which carries significant risk for recurrent events 1
• After initial CT, comprehensive vascular imaging should follow to identify potential carotid stenosis or other vascular abnormalities 1
• If carotid stenosis >70% is identified, carotid endarterectomy should be considered, with greatest benefit when performed within 2 weeks of symptom onset 2

Following this evidence-based approach will minimize the risk of recurrent stroke and optimize patient outcomes.