What is the recommended management for a patient with a history of stroke presenting with weakness and vertigo?

Management of Weakness and Vertigo in a Patient with Prior Stroke History

A patient with a history of stroke presenting with new weakness and vertigo requires immediate emergency department evaluation with urgent neuroimaging, as this presentation indicates very high risk for recurrent stroke and demands assessment within 24 hours.

Risk Stratification and Urgency

Timing is Critical for Determining Risk Level

The management approach depends entirely on when symptoms began:

If symptoms started within the last 48 hours:

• This patient is at VERY HIGH risk for recurrent stroke and requires immediate ED transfer 1
• The combination of weakness (a motor symptom) places them in the highest risk category 1
• Vertigo, particularly when accompanied by other neurologic symptoms, suggests possible posterior circulation involvement and increases stroke risk 2, 3
• These patients should be immediately sent to an emergency department with capacity for advanced stroke care (brain imaging on site and access to acute stroke treatments) 1

If symptoms started between 48 hours and 2 weeks ago:

• The patient remains at HIGH risk for recurrent stroke due to the presence of weakness 1
• They should receive comprehensive clinical evaluation and investigations by a healthcare professional with stroke expertise as soon as possible, ideally within 24 hours of first contact 1

If symptoms started more than 2 weeks ago:

• The patient is at LOWER risk but still requires evaluation by a neurologist or stroke specialist, ideally within one month 1

Essential Immediate Investigations

Neuroimaging Must Be Completed Urgently

For patients presenting within 48 hours (highest risk):

• Urgent brain imaging (CT or MRI) should be completed as soon as possible within 24 hours 1
• Noninvasive vascular imaging (CTA or MRA from aortic arch to vertex) should be completed within 24 hours 1
• An electrocardiogram should be completed without delay 1

Important imaging considerations:

• Noncontrast CT has very low sensitivity (28.5%) for acute stroke, missing approximately 71.5% of strokes 4
• MRI has much higher sensitivity (79.8%) but will still miss approximately one in five patients with stroke if obtained early after symptom onset 4
• Neuroimaging alone cannot rule out stroke - clinical assessment remains essential 4

Additional Required Investigations

• 12-lead ECG to evaluate for atrial fibrillation or other cardiac sources of embolism 1
• Laboratory investigations as part of initial assessment 1
• CTA including both extracranial and intracranial vasculature from aortic arch to vertex should be performed at the time of initial brain CT 1

Clinical Assessment Priorities

Distinguishing Central vs. Peripheral Causes of Vertigo

Key clinical features suggesting stroke (central cause):

• Vertigo accompanied by weakness is highly concerning for posterior circulation stroke 2
• Patients hospitalized for isolated vertigo have a 3.01-times higher risk for subsequent stroke compared to the general population 3
• Dizziness is the most common symptom of posterior circulation TIA and can precede posterior circulation strokes 2

Critical pitfall to avoid:

• The HINTS examination (Head Impulse, Nystagmus, Test of Skew), when performed by emergency physicians alone, has insufficient accuracy (sensitivity 83%, specificity 44%) to rule out stroke in patients with acute vestibular syndrome 5
• Do not rely on HINTS examination alone to exclude stroke - neuroimaging and specialist evaluation are required 5

Management Strategy

Immediate Actions for High-Risk Patients

1. Transfer to appropriate facility: Send immediately to an ED with advanced stroke care capabilities (brain and vascular imaging on site, access to thrombolysis/endovascular therapy) 1

2. Initiate secondary prevention measures: Once stroke is confirmed or strongly suspected, aggressive medical management should include antiplatelet therapy, statin use, and risk factor modification 2

3. Evaluate for carotid revascularization: Extracranial vascular imaging is essential to identify extracranial carotid stenosis for which patients should be referred for possible carotid revascularization 1

Risk Factor Considerations

• Vertigo patients with ≥3 vascular risk factors have a 5.51-fold higher risk for stroke compared to those without risk factors 3
• Given this patient's history of prior stroke, they already have at least one major risk factor, placing them at substantially elevated risk 3

Common Pitfalls to Avoid

• Do not assume vertigo is benign - in a patient with prior stroke, this symptom combined with weakness demands urgent evaluation 2, 3
• Do not rely solely on CT imaging - its sensitivity for acute stroke is only 28.5%, and many strokes will be missed 4
• Do not use HINTS examination as the sole decision tool - it lacks sufficient accuracy when performed by emergency physicians 5
• Do not delay evaluation - the risk of recurrent stroke is highest in the first 48 hours and first week after symptom onset 1