What is the management approach for a patient presenting with focal or neurological deficit?

Management of Focal or Neurological Deficit

In patients presenting with focal or neurological deficits, urgent revascularization is recommended when neurological deficit is present, with diagnostic imaging performed to guide treatment provided it does not delay intervention. 1

Immediate Assessment and Stabilization

Pre-Hospital and Emergency Department Priorities

• Airway control and ventilation management are critical priorities - tracheal intubation with mechanical ventilation and end-tidal CO2 monitoring should be implemented immediately, even in the pre-hospital setting, to prevent hypocapnia-induced cerebral vasoconstriction and brain ischemia 1

• Maintain systolic blood pressure >110 mmHg prior to measuring cerebral perfusion pressure, as even a single episode of hypotension (SBP <90 mmHg) significantly worsens neurological outcomes 1

• Rapid correction of hypotension requires vasopressor drugs (phenylephrine or norepinephrine) rather than waiting for delayed effects from fluid resuscitation or sedative dose reduction 1

• Analgesics should be administered as soon as possible for pain control in patients with acute limb ischemia presenting with neurological deficit 1

Diagnostic Imaging Protocol

Immediate Neuroimaging

• CT head without contrast is the first-line imaging modality and must be performed without delay in patients with coma or abnormal neurological examination to diagnose primary brain lesions and guide neurosurgical procedures 1

• CT angiography from aortic arch to vertex should be performed early in patients with risk factors including: cervical spine fracture, focal neurological deficit unexplained by brain imaging, Claude Bernard-Horner syndrome, Lefort II/III facial fractures, basilar skull fractures, or soft tissue neck lesions 1, 2

• MRI brain with diffusion-weighted imaging is preferred over CT to detect silent ischemic changes in the posterior circulation territory that may not be clinically apparent 2

Context-Specific Imaging Considerations

In acute limb ischemia with neurological deficit: Diagnostic imaging is recommended to guide treatment, provided it does not delay revascularization or if the need for primary amputation is obvious 1

In traumatic brain injury: The entire brain should be explored with inframillimetric sections reconstructed with thickness >1 mm, visualized with double fenestration (CNS and bones) 1

In suspected arterial dissection: If CT-angiography is normal but suspicion remains high, complete evaluation with MR-angiography or digital subtraction angiography 1

Urgent Revascularization Decisions

Acute Limb Ischemia with Neurological Deficit

• Urgent revascularization is mandatory (Class I, Level C recommendation) when neurological deficit is present 1

• Evaluation by an experienced vascular clinician must be performed urgently to assess limb viability and implement appropriate therapy 1

• In the absence of severe neurological deficit, revascularization is still recommended within hours of initial imaging on a case-by-case basis 1

Cerebrovascular Events

For symptomatic carotid stenosis: DAPT with low-dose aspirin and clopidogrel (75 mg) is recommended for the first 21 days or longer if not undergoing revascularization, followed by clopidogrel 75 mg or long-term aspirin 1

For vertebrobasilar insufficiency: Patients with symptoms like dizziness, visual phenomena, positional tinnitus, and bilateral sensory symptoms are at high risk for stroke if untreated, with 10% risk of completed stroke within the first week (highest in first 48 hours) 2

Post-Revascularization Monitoring

Critical Surveillance

• Monitor for compartment syndrome after revascularization and treat with fasciotomy when indicated 1

• Assess clinical and hemodynamic success following revascularization to ensure adequate perfusion restoration 1

• Regular follow-up is mandatory - assess clinical, hemodynamic and functional status, limb symptoms, treatment adherence, and cardiovascular risk factors 1

Anticoagulation Strategy

• Following revascularization for acute limb ischemia, if not on anticoagulation for other reasons: Consider DAPT or rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg once daily) 1

• Upon confirmation of acute limb ischemia diagnosis: Treatment with heparin may be considered 1

Etiological Investigation

• Obtain comprehensive medical history and determine the cause of thrombosis and/or embolization in all patients with acute limb ischemia 1

• Measure blood pressure in both arms to detect subclavian steal phenomenon, as a difference ≥15 mmHg is highly suspicious for proximal arterial stenosis contributing to vertebrobasilar insufficiency 2

• Document all positional triggers systematically: Which head positions worsen symptoms, which sleeping positions cause morning manifestations, and which movements trigger specific sensations 2

Common Pitfalls to Avoid

• Never delay revascularization for imaging when neurological deficit is present and limb viability is threatened - imaging should guide treatment only if it doesn't cause delay 1

• Do not dismiss positional symptoms as psychogenic - symptoms that change with position indicate real hemodynamic compromise affecting already-compromised vascular flow 2

• Avoid hypotensive sedation induction - use continuous sedation rather than boluses, correct hypovolemia, and adjust mechanical ventilation to facilitate central venous return 1

• Do not use ECST method for carotid stenosis assessment - use NASCET method or its non-invasive equivalent instead 1