What are the next steps for a patient with a history of Cerebrovascular Accident (CVA) presenting with left-sided pressure over the back of the head and associated numbness?

Urgent Neurological Evaluation for Possible Recurrent Stroke or Posterior Circulation Ischemia

This patient requires immediate emergency department evaluation with urgent brain imaging (MRI with diffusion-weighted imaging preferred, or CT if MRI unavailable) to rule out acute ischemic stroke, particularly in the posterior circulation, given the concerning combination of focal neurological symptoms and prior stroke history. 1, 2

Immediate Actions Required

Treat this as a stroke emergency until proven otherwise. The combination of new-onset focal neurological symptoms (left-sided pressure with numbness) in a patient with prior CVA history represents a high-risk presentation that demands urgent evaluation within hours, not days. 3, 4

Priority Diagnostic Steps

• Obtain urgent brain MRI with diffusion-weighted imaging (DWI) to detect acute ischemia, as DWI can identify acute infarcts that CT may miss, particularly in the posterior circulation 5, 1
• If MRI is unavailable or delayed, proceed immediately with non-contrast CT brain to exclude hemorrhage and large territory infarction 2
• Document precise time of symptom onset as this determines eligibility for thrombolytic therapy (rtPA effective within 3-4.5 hours) 2
• Perform MRA or CTA of head and neck to evaluate for large vessel occlusion, particularly vertebrobasilar system given the location of symptoms 5, 1

Critical Clinical Assessment

The left-sided pressure over the back of the head with numbness raises specific concern for:

• Posterior circulation ischemia (vertebrobasilar territory), which can present with occipital headache and sensory symptoms 6, 7
• Progressive or recurrent stroke, as patients with prior CVA have significantly elevated risk of recurrence (CHADS₂ score ≥2 increases risk 4-7 fold) 8
• Vertebral artery dissection, which classically presents with posterior neck/occipital pain and can progress to stroke 5

Examine specifically for:

• Cranial nerve deficits (particularly extraocular movements, facial sensation, dysarthria) 6
• Cerebellar signs (ataxia, nystagmus, dysmetria) 6
• Contralateral motor or sensory deficits 7
• Vital signs including blood pressure in both arms (dissection consideration) 5

Risk Stratification

This patient is high-risk based on:

• Prior CVA history (9.5-fold increased risk of periprocedural CVA, likely similar for spontaneous recurrence) 8
• New focal neurological symptoms warrant same urgency as TIA, which carries 3-6% stroke risk within first week 5
• Posterior circulation symptoms can be initially subtle but progress to devastating outcomes, with basilar artery occlusion carrying 45-86% mortality 6

Acute Management Considerations

If acute ischemic stroke is confirmed:

• Administer IV rtPA (0.9 mg/kg, max 90 mg) if within 3-4.5 hour window and no contraindications 2
• Maintain blood pressure <180/105 mmHg if thrombolysis given, but otherwise allow permissive hypertension to maintain cerebral perfusion 2
• Consider mechanical thrombectomy if large vessel occlusion identified, particularly in posterior circulation 1
• Start aspirin 160-300 mg within 48 hours (typically 24 hours post-thrombolysis if given) 2

If imaging is negative but symptoms persist:

• Admit for observation and serial neurological assessments as posterior circulation strokes can be initially missed on CT and symptoms may fluctuate 6
• Repeat MRI with DWI in 24-48 hours if initial imaging negative but clinical suspicion remains high 1
• Initiate antiplatelet therapy (aspirin or dual antiplatelet therapy depending on vascular imaging results) 5, 2

Common Pitfalls to Avoid

• Do not dismiss symptoms as "tension headache" or "cervical radiculopathy" in a patient with prior stroke—always image urgently 3, 4
• Do not delay imaging for "observation"—posterior circulation strokes are frequently missed or diagnosed late, leading to worse outcomes 6
• Do not assume normal CT excludes stroke—MRI with DWI is far more sensitive, particularly for posterior circulation and small vessel disease 5, 1
• Do not aggressively lower blood pressure unless giving thrombolytics or BP >220/120 mmHg, as this may worsen cerebral perfusion 2

Secondary Prevention Workup

Once acute stroke is excluded or treated, comprehensive evaluation should include:

• Carotid duplex ultrasonography to assess for stenosis 5
• Prolonged cardiac monitoring (minimum 24 hours) to detect atrial fibrillation 2
• Echocardiography if no severe extracranial disease found to evaluate for cardioembolic source 5
• Fasting lipid panel and glucose to optimize vascular risk factor management 1, 2

Initiate statin therapy regardless of baseline cholesterol and optimize blood pressure control after the acute phase 2