What is the best course of action for a patient with a history of cerebrovascular accident (CVA) presenting with left-sided weakness and dizziness?

Immediate Emergency Evaluation Required

This patient requires immediate emergency department evaluation at a stroke center with urgent brain imaging (CT or MRI) within 24 hours, as left-sided weakness and dizziness in a patient with prior CVA represents a very high-risk presentation for recurrent stroke. 1, 2

Risk Stratification

This patient falls into the VERY HIGH RISK category for recurrent stroke based on:

• Unilateral weakness (left-sided) presenting as a focal neurological deficit 1
• History of prior CVA, which significantly increases recurrence risk 1
• Symptom onset within 48 hours (assuming acute presentation) 1

The risk of recurrent stroke is highest in the first 48 hours to 2 weeks, with rates of 1.5% at 2 days, 2.1% at 7 days, and 2.8% at 30 days even with optimal management 1. Without immediate intervention, historical rates approach 10.3% at 90 days 1.

Immediate Actions Required

Emergency Department Transfer

• Send immediately to an emergency department with capacity for advanced stroke care, including on-site brain imaging and access to acute stroke treatments 1
• Use emergency transport systems rather than routine referral 3

Urgent Diagnostic Workup (Within 24 Hours)

Brain Imaging: 1

• MRI with diffusion-weighted imaging (DWI) is preferred over CT for detecting acute infarction 1
• If MRI unavailable, perform head CT immediately 1
• Up to 24% of patients with acute focal symptoms have concurrent cerebrovascular accident on DWI-MRI 1

Vascular Imaging: 1

• Noninvasive imaging of cervicocephalic vessels (CTA or MRA from aortic arch to vertex) within 24 hours 1
• Carotid ultrasound/transcranial Doppler if CTA/MRA unavailable 1
• Up to 70% of patients with symptomatic presentations have clinically significant carotid stenosis discovered 1

Cardiac Evaluation: 1

• Electrocardiogram without delay 1
• Prolonged cardiac monitoring (inpatient telemetry or Holter) if etiology unclear 1
• Echocardiography (at least transthoracic) to identify cardioembolic sources 1

Laboratory Tests: 1

• Complete blood count with platelets
• Chemistry panel, hemoglobin A1C
• Prothrombin time and partial thromboplastin time
• Fasting lipid panel
• Erythrocyte sedimentation rate and C-reactive protein (if age >50 years to screen for giant cell arteritis) 1

Acute Treatment Considerations

Time-Sensitive Interventions

• Assess "last known well" time immediately to determine eligibility for thrombolysis 2
• Intravenous thrombolysis (rtPA) if patient presents within 3-4.5 hours of symptom onset and meets eligibility criteria 2
• Endovascular treatment may be considered based on imaging findings and time window 2

Blood Pressure Management 2

• If NOT receiving thrombolysis: Treat only if diastolic BP >120 mmHg or systolic BP >220 mmHg
• If receiving thrombolysis: Maintain BP <185/110 mmHg before treatment and for 24 hours after

Clinical Pitfalls to Avoid

Do not dismiss dizziness as benign vertigo in this high-risk patient. While isolated dizziness may represent peripheral causes, the combination with left-sided weakness indicates a central process requiring urgent evaluation 1.

Do not rely solely on clinical examination to rule out stroke. Focal neurologic symptoms/signs may be lacking in one-third to two-thirds of patients with posterior circulation infarcts 1. The NIHSS may underestimate stroke severity when cognitive, sensory, or visuospatial deficits predominate 4.

Do not delay imaging for "observation." Silent brain infarction is present in 19-25% of patients with acute vascular events, and these silent infarctions carry high risk for future stroke 1.

Likely Localization Based on Symptoms

Given left-sided weakness and dizziness, consider:

• Right hemisphere stroke (causing contralateral left weakness) involving motor cortex, internal capsule, or basal ganglia 2, 5
• Posterior circulation involvement if dizziness is prominent, suggesting vertebrobasilar territory 1
• Right parietal lobe involvement may present with left-sided weakness, sensory loss, and spatial disorientation 5

Post-Acute Management Planning

Once acute stroke is confirmed or excluded:

• Antiplatelet therapy (aspirin, clopidogrel, or combination based on etiology) for secondary prevention 2
• Anticoagulation if cardioembolic source identified (e.g., atrial fibrillation) 2
• Early mobilization when medically stable 2
• Comprehensive rehabilitation addressing motor, speech, cognitive deficits, and activities of daily living 2