What is the diagnosis and management for a 43-year-old woman with acute onset of weakness in one arm, pain in the back of the head and neck, stiffness in the shoulder, and hypertension (high blood pressure), despite having normal motor strength (5/5) in the upper extremity?

Differential Diagnosis and Management

This patient most likely has a transient ischemic attack (TIA) or minor stroke presenting as a VERY HIGH risk case requiring immediate emergency department evaluation with brain and vascular imaging within 24 hours, despite the paradoxically normal motor examination. 1

Critical Clinical Assessment

The presentation of subjective arm weakness with normal motor strength (5/5) in a 43-year-old woman with acute onset (2 days), posterior head/neck pain, shoulder stiffness, and hypertension (160/100 mmHg) creates a diagnostic challenge that demands urgent cerebrovascular evaluation.

Primary Differential Diagnoses

1. Transient Ischemic Attack (TIA) or Minor Stroke (Most Likely)

• Patients presenting within 48 hours of transient or fluctuating unilateral weakness are considered at VERY HIGH risk for recurrent stroke, even when current examination appears normal 1
• The 2-day history of weakness with posterior head/neck pain raises concern for vertebrobasilar insufficiency or posterior circulation involvement 1
• Normal motor examination does not exclude TIA—symptoms may have resolved but risk remains extremely high, with 2-day stroke recurrence rates of 1.5% and 7-day rates of 2.1% even with optimal management 1

2. Cervical Arterial Dissection

• Posterior head/neck pain with arm symptoms in a young patient is a classic presentation for vertebral or carotid artery dissection 1
• This represents a stroke emergency requiring urgent vascular imaging from aortic arch to vertex 1

3. Hypertensive Emergency (Less Likely)

• Blood pressure of 160/100 mmHg does NOT meet criteria for hypertensive emergency (requires >180/120 mmHg with acute organ damage) 1
• However, the neurological symptoms mandate evaluation for hypertension-mediated organ damage 1

4. Cervical Radiculopathy or Musculoskeletal (Least Likely)

• While shoulder stiffness might suggest musculoskeletal etiology, the acute onset with posterior head pain and subjective weakness pattern is too concerning for cerebrovascular disease to attribute to benign causes 1

Immediate Management Algorithm

Step 1: Emergency Department Referral (Within Hours)

This patient requires IMMEDIATE transfer to an emergency department with advanced stroke care capabilities (brain imaging on-site and access to acute stroke treatments) 1

• Patients with transient or fluctuating unilateral weakness within 48 hours are classified as VERY HIGH risk and should be immediately sent to an ED 1
• The combination of subjective weakness, posterior head/neck pain, and hypertension creates a stroke syndrome that cannot be safely managed in outpatient settings 1

Step 2: Urgent Diagnostic Evaluation (Within 24 Hours)

Brain Imaging:

• CT or MRI brain must be completed as soon as possible within 24 hours 1
• This identifies acute infarction, hemorrhage, or other structural lesions 1

Vascular Imaging:

• CTA or MRA from aortic arch to vertex is essential within 24 hours 1
• This evaluates for arterial dissection, stenosis, or occlusion that may require urgent intervention 1

Cardiac Evaluation:

• ECG should be completed without delay 1
• Assess for atrial fibrillation or other arrhythmias that increase stroke risk 1

Laboratory Assessment:

• Complete blood count, platelets, creatinine, sodium, potassium, glucose 2
• Lipid panel and hemoglobin A1c for cardiovascular risk stratification 1

Step 3: Blood Pressure Management

DO NOT aggressively lower blood pressure in the acute setting 1

• In acute ischemic stroke, blood pressure should NOT be reduced within the first 5-7 days unless BP exceeds 220/120 mmHg 1, 2
• Current BP of 160/100 mmHg does not require acute reduction and may be permissive hypertension supporting cerebral perfusion 1
• If extremely high BP exists (>220/120 mmHg), cautiously reduce by no more than 10-20% and observe for neurological deterioration 1
• Pre-existing antihypertensive therapy may be continued provided there is no symptomatic hypotension 1

Step 4: Acute Stroke Treatment Considerations

If imaging confirms acute ischemic stroke:

• Aspirin 150-300 mg should be given as soon as possible after stroke onset (within 48 hours) if CT/MRI excludes hemorrhage 1
• Thrombolysis eligibility must be assessed if patient presents within appropriate time window 1
• The routine use of anticoagulation (IV heparin) in unselected patients is NOT recommended 1

If imaging is negative but high clinical suspicion remains:

• Patient still requires comprehensive stroke prevention strategies through rapid-access TIA clinic 1
• Initiate antiplatelet therapy, statin, and blood pressure management for secondary prevention 1

Critical Pitfalls to Avoid

1. Dismissing Normal Motor Examination

• A normal neurological examination does NOT exclude TIA or minor stroke 1
• Transient symptoms that have resolved still confer VERY HIGH stroke risk requiring urgent evaluation 1

2. Aggressive Blood Pressure Reduction

• Lowering BP too rapidly in acute cerebrovascular events can precipitate cerebral ischemia through loss of autoregulation 1, 2
• BP of 160/100 mmHg is NOT a hypertensive emergency and does not require immediate reduction 1

3. Outpatient Management

• This patient should NOT be managed as an outpatient with scheduled follow-up 1
• VERY HIGH risk patients require immediate ED evaluation with imaging within 24 hours 1

4. Attributing Symptoms to Musculoskeletal Causes

• While shoulder stiffness might suggest cervical spine pathology, the acute onset with posterior head pain and arm weakness is a stroke syndrome until proven otherwise 1
• Missing arterial dissection or acute stroke has catastrophic consequences 1

Post-Stabilization Management

After acute evaluation and stabilization:

• Comprehensive stroke risk factor modification including blood pressure control to <130/80 mmHg for long-term management 3
• Antiplatelet therapy (aspirin or clopidogrel) for secondary stroke prevention 1
• Statin therapy for atherosclerotic disease prevention 1
• Screen for secondary hypertension causes given relatively young age 1, 2
• Address medication compliance and lifestyle modifications including smoking cessation, weight management, and dietary sodium reduction 3

The survival and functional outcomes for patients with TIA/minor stroke have improved dramatically with rapid access to stroke prevention strategies through dedicated TIA clinics, reducing 90-day stroke recurrence from 10.3% to 2.1% 1