What is the appropriate management for a patient presenting with dizziness and left-sided facial and body weakness, suggestive of a potential stroke or Transient Ischemic Attack (TIA)?

Management of Patient with Dizziness and Left-Sided Facial and Body Weakness

A patient presenting with dizziness and left-sided facial and body weakness should be immediately transported to an emergency department with advanced stroke care capabilities, as these symptoms strongly suggest a transient ischemic attack (TIA) or acute stroke requiring urgent evaluation and management.

Risk Assessment

• Patients with unilateral weakness (face, arm, and/or leg) and/or speech disturbance presenting within 48 hours of symptom onset are considered at VERY HIGH risk for recurrent stroke 1
• The risk of stroke after TIA can be as high as 10% within the first week of symptom onset, with the highest risk in the first 48 hours 1
• Recent data shows that with rapid access to specialized care, stroke recurrence rates have decreased to approximately 1.5% at 2 days and 2.1% at 7 days 1, 2
• Left-sided weakness with dizziness represents a classic presentation of right hemispheric cerebrovascular ischemia that requires immediate attention 2

Immediate Management (First 24 Hours)

• The patient should be immediately transported to an emergency department with advanced stroke care capabilities 1
• Urgent brain imaging must be completed without delay:
  • CT or MRI brain scan 1
  • Non-invasive vascular imaging (CTA or MRA from aortic arch to vertex) 1
• An electrocardiogram (ECG) should be completed without delay 1
• Basic laboratory investigations should include 1:
  • Complete blood count
  • Serum electrolytes and creatinine
  • Fasting blood glucose
  • Lipid profile

Imaging Considerations

• While CT is often the first-line imaging due to availability, MRI with diffusion-weighted imaging (DWI) is superior for detecting small ischemic lesions 3
• MRI detects acute ischemic lesions in 39% of TIAs versus only 8% with CT 3
• For minor strokes, MRI detects lesions in 86% of cases versus 18% with CT 3
• Carotid imaging (ultrasound, CTA, or MRA) should be performed to assess for carotid stenosis 1

Cardiac Evaluation

• Cardiac assessment should include 1:
  • 12-lead ECG to identify atrial fibrillation or other arrhythmias
  • Consideration of echocardiography (transthoracic and/or transesophageal) if a cardioembolic source is suspected
  • Extended cardiac monitoring if paroxysmal atrial fibrillation is suspected

Treatment Initiation

• Antiplatelet therapy should be initiated immediately unless contraindicated 4
• For patients without severe carotid stenosis or atrial fibrillation, dual antiplatelet therapy with aspirin and clopidogrel should be started within 24 hours of symptom onset and continued for 21 days, followed by single antiplatelet therapy 4
• This approach reduces stroke risk from 7.8% to 5.2% 4
• If significant carotid stenosis is identified, early carotid revascularization should be considered 1, 4
• If atrial fibrillation is detected, anticoagulation should be initiated 4

Follow-up and Secondary Prevention

• Risk factor modification should be addressed, including 1, 5:
  • Blood pressure control
  • Diabetes management
  • Smoking cessation
  • Lipid management
• Follow-up imaging may be necessary to monitor for disease progression 1

Common Pitfalls to Avoid

• Delaying evaluation beyond 24-48 hours significantly increases the risk of recurrent stroke 6
• Failing to recognize that TIAs occur most frequently during the hours and days immediately preceding a stroke (43% within 7 days prior) 6
• Misdiagnosing posterior circulation symptoms (like dizziness) as benign vertigo 1, 2
• Relying solely on CT imaging, which has only 20% sensitivity compared to MRI for detecting acute ischemic lesions 3

Special Considerations

• The combination of dizziness with unilateral weakness strongly suggests a central rather than peripheral cause 2
• Patients with multiple risk factors have a significantly higher risk of stroke following TIA 1, 5
• Posterior circulation symptoms may be more subtle but carry similar risk for recurrent stroke 1, 2