What is the management plan for a patient with transient hemiplegia that resolves within 24 hours, but MRI shows acute lacunar infarcts?

Management of Transient Hemiplegia with MRI-Confirmed Acute Lacunar Infarcts

This patient has had a completed stroke, not a TIA, and should be managed as an acute ischemic stroke with aggressive secondary prevention including hospitalization for expedited workup, dual antiplatelet therapy, and comprehensive vascular imaging. 1, 2

Critical Diagnostic Clarification

The presence of acute infarction on MRI—even with symptom resolution within 24 hours—reclassifies this event from TIA to completed stroke. 2, 3 This distinction fundamentally changes management priorities:

• DWI-positive lesions indicate irreversible tissue injury and confer significantly higher risk for recurrent ischemic events compared to DWI-negative transient symptoms 2, 3
• The clinical syndrome may have been lacunar (pure motor hemiplegia), but lacunar syndromes can result from large vessel occlusion or cardioembolic sources in up to 16% of cases, making comprehensive vascular evaluation mandatory 4

Immediate Management (First 24-48 Hours)

Hospitalization Decision

Admit this patient immediately based on the following criteria from National Stroke Association guidelines 1:

• Abnormal brain DWI-MRI showing acute cerebral infarction
• Presentation within 72 hours of symptom onset
• Need for expedited comprehensive stroke workup

Antiplatelet Therapy

Initiate dual antiplatelet therapy (DAPT) with aspirin 81-325 mg plus clopidogrel 75 mg daily for 21 days, then transition to single antiplatelet agent 5:

• DAPT reduces recurrent stroke risk by 24% (RR 0.76,95% CI 0.68-0.83) when initiated within 24 hours of minor stroke or high-risk TIA 5
• The increased major bleeding risk (RR 2.22) is acceptable given the substantial reduction in recurrent ischemic events 5
• Do not use DAPT if thrombolysis was administered or if significant bleeding risk exists 5

Comprehensive Diagnostic Workup (Within 24 Hours)

Vascular Imaging (Mandatory)

Obtain CTA head and neck or MRA head and neck immediately to identify treatable vascular lesions 1, 2, 3, 6:

• Assess for carotid stenosis ≥50% requiring revascularization 1, 6
• Evaluate for intracranial atherosclerotic disease or vertebrobasilar pathology 6
• Critical pitfall: Lacunar syndromes do not exclude large vessel disease—angiography is essential even with lacunar-sized infarcts on imaging 4

Cardiac Evaluation

Perform the following cardiac assessments 1, 6:

• ECG immediately to detect atrial fibrillation 1
• Continuous telemetry monitoring for minimum 24 hours 1
• Transthoracic echocardiography (can be outpatient if initial cardiac workup normal) 1
• Arrange prolonged cardiac monitoring (30-day event monitor or implantable loop recorder) if initial evaluation unrevealing, as this detects atrial fibrillation in 16.1% of cryptogenic cases versus 3.2% with standard monitoring 6

Laboratory Studies

Obtain standard stroke panel 1:

• Complete blood count with platelets
• Comprehensive metabolic panel
• Hemoglobin A1C
• Fasting lipid panel
• PT/PTT if anticoagulation considered

Secondary Prevention Strategy

Blood Pressure Management

Target blood pressure <130/80 mmHg using ACE inhibitors or ARBs as first-line agents 6:

• Initiate during hospitalization once acute phase complete
• Hypertension is the dominant risk factor for lacunar stroke progression 7

Lipid Management

Initiate high-intensity statin therapy regardless of baseline LDL 6, 7:

• Statins are key elements in secondary prevention after lacunar stroke 7
• Begin during hospitalization

Glycemic Control

Target HbA1c <7% if diabetic, as diabetes is a major risk factor for lacunar stroke 7

Anticoagulation Decision

Switch from antiplatelet therapy to anticoagulation if 6:

• Atrial fibrillation detected on extended monitoring
• Cardioembolic source identified (left ventricular thrombus, mechanical valve, etc.)
• Do not anticoagulate for lacunar stroke alone—historical data show no benefit and potential harm 8

Critical Pitfalls to Avoid

1. Misclassifying as TIA: The presence of acute infarction on DWI makes this a completed stroke requiring more aggressive management than symptom-negative TIA 2, 3

2. Assuming benign prognosis: Despite favorable short-term outcomes, lacunar infarcts carry increased mid- and long-term risk of death, stroke recurrence, and dementia due to progressive small vessel disease 7

3. Skipping vascular imaging: Lacunar syndromes can result from large vessel disease requiring revascularization—never assume small vessel etiology without comprehensive vascular evaluation 4

4. Inadequate cardiac monitoring: Standard 24-hour Holter monitoring misses most paroxysmal atrial fibrillation—extended monitoring (30 days minimum) is required for cryptogenic cases 6

5. Using anticoagulation for lacunar stroke: Heparin showed no benefit and potential harm in lacunar stroke progression 8

Follow-Up Protocol

• Neurology follow-up within 2 weeks of discharge 1
• Repeat vascular imaging only if new symptoms develop—do not perform surveillance imaging of stable infarcts 6
• Continue extended cardiac monitoring for 30 days minimum if no source identified 6
• Aggressive risk factor modification with lifestyle interventions (smoking cessation, Mediterranean diet, regular aerobic exercise) 6