What is the most appropriate management for a patient with transient memory loss that resolved in the Emergency Department (ED)?

Discharge the Patient

This patient should be discharged from the ED with appropriate counseling about transient global amnesia (TGA), as her clinical presentation and complete symptom resolution are consistent with this benign, self-limited condition that requires no specific treatment or admission.

Clinical Reasoning for TGA Diagnosis

This patient's presentation is classic for transient global amnesia:

• Sudden onset of anterograde amnesia (inability to form new memories about the dinner party and appointments) with preserved personal identity and recognition of her spouse 1, 2
• Normal neurological examination including intact strength, sensation, gait, and ability to recall objects at testing intervals 1, 3
• Preserved remote memory (knows spouse's name and childhood details) while unable to recall recent events 1, 4
• Complete resolution within 24 hours while still in the ED, which is pathognomonic for TGA 1, 3, 4
• Unremarkable workup including normal CT head, labs, and vital signs 1, 2

Why Admission is Not Indicated

The American College of Emergency Physicians guidelines for mild traumatic brain injury establish that patients with normal neurological examinations, normal vital signs, and negative imaging can be safely discharged 5, 6. While this patient did not have head trauma, the same principle of safe discharge applies when dangerous pathology has been excluded:

• No evidence of stroke or TIA: Normal neurological exam, no focal deficits, and symptoms completely resolved 1
• No intracranial pathology: Normal CT head rules out hemorrhage, mass effect, or acute structural lesions 2
• TGA is a benign condition: It is self-limited with excellent prognosis and no specific treatment required 1, 3, 4
• Observation period completed: The patient's complete recovery in the ED serves as the observation period, confirming the diagnosis 3

Why Neurology Consultation is Not Required

Neurology consultation in the ED is unnecessary because:

• TGA is a clinical diagnosis that has already been confirmed by symptom resolution 1, 4
• No ongoing neurological deficit exists that requires specialist input 1, 3
• The differential diagnoses requiring urgent neurological intervention (stroke, seizure, encephalitis) have been effectively ruled out by normal examination, imaging, and symptom resolution 1, 2

Why MRI is Not Indicated

Advanced imaging with MRI is not necessary for management because:

• The diagnosis is already established by clinical criteria and symptom resolution 1, 3
• MRI findings do not change management: While DWI-MRI may show punctate hippocampal lesions in TGA, these are transient and do not require treatment 2, 4
• CT has already excluded emergent pathology that would require immediate intervention 2
• MRI would only be considered if symptoms had not resolved or if alternative diagnoses remained under consideration 2

Appropriate Discharge Management

The patient should receive specific discharge instructions:

• Reassurance about the benign nature of TGA and expected full recovery 1, 3, 4
• Education about recurrence risk of approximately 18%, though most patients never experience another episode 4
• Return precautions for new neurological symptoms, persistent memory problems, or any concerning features 6
• No specific therapy or prophylaxis is indicated, including no need for antithrombotic treatment 4
• Outpatient neurology follow-up can be arranged electively if the patient or primary care physician desires further evaluation, but is not emergently required 1

Common Pitfalls to Avoid

• Over-investigating a resolved clinical syndrome: Once TGA is diagnosed and symptoms have resolved, additional testing adds no value and may lead to incidental findings requiring unnecessary follow-up 1, 3
• Admitting for "observation" after complete recovery: This provides no benefit when the diagnostic observation period has already occurred in the ED 3
• Treating as stroke or TIA: TGA requires no antithrombotic therapy or stroke workup when classic features are present and resolution occurs 4
• Failing to provide reassurance: Patients and families may be frightened by the dramatic presentation and need clear explanation of the benign prognosis 1, 3