What is the next step in treating a 52-year-old woman with a history of relapsing-remitting Multiple Sclerosis (MS), Hypertension (HTN), and Hyperlipidemia, who presents with transient speech arrest and right arm weakness?

Management of Transient Ischemic Attack in a Patient with Multiple Sclerosis

The patient should be initiated on aspirin and statin therapy (option A) as the next step in treatment.

Clinical Assessment and Diagnosis

This 52-year-old woman presents with:

• Sudden onset speech arrest and right arm weakness lasting 30 minutes
• History of relapsing-remitting multiple sclerosis (RRMS)
• Hypertension and hyperlipidemia
• No current disease-modifying therapy for MS
• Elevated blood pressure (170/96 mmHg)
• BMI of 35 kg/m²
• Left eye afferent pupillary defect with diminished visual acuity

These symptoms are consistent with a transient ischemic attack (TIA), which represents a medical emergency requiring prompt intervention to prevent progression to stroke.

Rationale for Aspirin and Statin Therapy

1. Evidence for Antiplatelet Therapy:

   • Antiplatelet therapy is the mainstay for non-cardioembolic ischemic events 1
   • The Canadian Stroke Best Practice Recommendations indicate that patients with very high-risk TIA should receive antiplatelet therapy 1
   • For patients with TIA, aspirin should be initiated immediately to reduce the risk of recurrent stroke 1

2. Evidence for Statin Therapy:

   • High-intensity statin therapy is recommended for patients with ischemic stroke or TIA 2
   • For patients with ischemic stroke or TIA and atherosclerotic disease, statin therapy with a goal LDL-C of <70 mg/dL is recommended 2
   • Statin therapy has demonstrated a 19% relative risk reduction in ischemic stroke 2

3. Comorbidity Management:

   • Hypertension and hyperlipidemia are significant risk factors for stroke and require aggressive management 1
   • Target blood pressure should be <130/80 mmHg for most patients with prior stroke or TIA 1, 2
   • Vascular comorbidities may contribute to progression in MS 3, 4

Why Other Options Are Not Appropriate

• Option B (Disease-modifying agent for MS): While the patient has RRMS without current disease-modifying therapy, her immediate presentation is consistent with a TIA rather than an MS relapse. The sudden onset and resolution of focal neurological deficits point to a vascular etiology. MS management should be addressed after the acute vascular event is managed 3.

• Option C (Intravenous heparin infusion): There is insufficient evidence supporting the use of heparin for TIA management. Antiplatelet therapy is the standard of care for non-cardioembolic TIAs 1.

• Option D (Plasma exchange): This therapy is not indicated for TIA management and would be inappropriate in this clinical scenario.

Comprehensive Management Approach

1. Immediate Interventions:

   • Start aspirin (initial dose 160-325 mg) 1
   • Initiate high-intensity statin therapy (preferably atorvastatin 80 mg daily) 2
   • Aggressively control blood pressure with target <130/80 mmHg 1

2. Additional Considerations:

   • Monitor for 24 hours for neurological changes
   • Consider carotid imaging to evaluate for significant stenosis
   • Address modifiable risk factors (obesity, hypertension, hyperlipidemia)

3. MS Management:

   • After stabilizing the vascular event, evaluate for appropriate disease-modifying therapy for RRMS
   • Consider the interaction between MS and vascular comorbidities 5, 6, 4

Important Clinical Considerations

• Patients with MS have a higher prevalence of vascular risk factors including hypertension (8.8%) and hyperlipidemia (10%) 5
• Hypertension and heart disease contribute to advanced brain atrophy in MS patients 4
• Vascular comorbidities may accelerate neurodegeneration in MS 6, 4, 7
• Regular monitoring of lipid levels and blood pressure is essential in MS patients with vascular risk factors 2

The management of this patient requires addressing both her acute vascular event and underlying chronic conditions, with immediate focus on preventing stroke recurrence through antiplatelet and statin therapy.