What are the immediate treatment steps for a patient presenting with headache, dizziness, and left side neglect, potentially indicating a stroke or Transient Ischemic Attack (TIA)?

Immediate Management of Suspected Acute Stroke

This patient requires immediate emergency activation and transport to a stroke center—headache with dizziness and left-sided neglect represents a high-probability acute stroke syndrome requiring urgent brain imaging and consideration for thrombolytic therapy or mechanical thrombectomy within minutes to hours. 1, 2

Immediate Actions (First 15 Minutes)

Call 911 and Activate Emergency Response

• Immediately activate EMS (call 911) for any patient with sudden neurological symptoms including unilateral weakness, sensory loss, visual disturbances, speech difficulties, or coordination problems 1
• Left-sided neglect combined with headache and dizziness strongly suggests right hemisphere stroke, particularly in the middle cerebral artery territory 1
• EMS dispatch should be notified this is a suspected stroke for high-priority response 1

Prehospital Assessment

• EMS personnel should perform the Cincinnati Prehospital Stroke Scale assessing facial droop, arm drift, and abnormal speech—if any one of these is abnormal, stroke probability is 72% 1
• Document exact time of symptom onset or last known well time, as this determines eligibility for time-sensitive interventions 1, 3
• Provide supplementary oxygen only if oxygen saturation <94% 1
• Do NOT treat elevated blood pressure in the prehospital setting unless systolic BP <90 mm Hg 1

Transport Destination

• Direct transport to a designated stroke center with capacity for advanced imaging (CT/MRI and CTA/MRA) and thrombolytic therapy on-site 1
• Prehospital notification to receiving hospital is mandatory to activate stroke team 1

Emergency Department Management (First 60 Minutes)

Immediate Diagnostic Workup

• Brain imaging (MRI with diffusion-weighted imaging preferred; CT if MRI unavailable) must be completed immediately upon arrival 2, 4, 5
• Vascular imaging (CTA or MRA from aortic arch to vertex) should be performed without delay 1, 2
• ECG immediately upon arrival 1, 2
• Laboratory tests: CBC, electrolytes, creatinine, glucose, HbA1c, lipid panel, PT/PTT 2

Risk Stratification

This patient meets HIGHEST risk criteria for acute stroke requiring immediate ED evaluation: 1, 2

• Presenting with unilateral neurological deficit (left-sided neglect)
• Symptoms are acute and potentially fluctuating
• Left-sided neglect indicates right hemisphere involvement, often associated with motor or sensory deficits

Time-Sensitive Treatment Decisions

For Disabling Stroke (Interfering with Activities of Daily Living)

• Intravenous alteplase within 3 hours of symptom onset improves likelihood of minimal/no disability from 26% to 39% 3
• IV alteplase within 3-4.5 hours improves outcomes from 30.1% to 35.3% 3
• Mechanical thrombectomy for large vessel occlusion within 6 hours increases functional independence from 26.5% to 46% 3
• Thrombectomy can be performed 6-24 hours after onset if large ischemic penumbra on perfusion imaging (functional independence 53% vs 18%) 3

For High-Risk TIA or Minor Stroke (Non-Disabling)

• Dual antiplatelet therapy (aspirin plus clopidogrel) initiated within 24 hours and continued for 3 weeks reduces stroke risk from 7.8% to 5.2% 3
• This applies to patients with ABCD2 score ≥4 or NIHSS ≤3-5 without severe carotid stenosis or atrial fibrillation 3

Admission Criteria

This patient should be admitted to a stroke unit based on: 2

• Acute presentation with neurological deficit (left-sided neglect)
• Need for continuous cardiac monitoring
• Completion of diagnostic workup including echocardiography
• Assessment for embolic source requiring immediate treatment
• Evaluation for carotid stenosis ≥50% requiring urgent revascularization 2

Critical Time Windows

The window for intervention is extremely narrow—43% of strokes preceded by TIA occur within 7 days, with 17% on the same day and 9% the next day 6. The highest stroke risk after TIA is within the first 48 hours, with risk as high as 10% in the first week 4, 5.

Key Pitfalls to Avoid

• Never discharge patients with crescendo or fluctuating symptoms under any circumstances 2
• Never delay carotid imaging in patients with anterior circulation symptoms 2
• Never rely solely on ABCD2 scores for disposition decisions—clinical judgment and imaging findings are paramount 2
• Never assume symptoms are "just dizziness"—dizziness combined with other neurological signs (like neglect) indicates central vascular cause requiring immediate stroke workup 7

budget:budget_used Tokens used this turn: 2508 Total tokens used in conversation: 2508 Remaining budget: 197492 tokens