What is the best course of action for a 40-year-old female (F) with a history of hypertension, who experienced a transient episode of slurred speech, inability to protrude her tongue, and difficulty ambulating after a fall, but had complete resolution of symptoms by morning, and a negative cranial computed tomography (CT) scan?

Management of Transient Neurological Symptoms in a Hypertensive Patient Post-Fall

This patient experienced a transient ischemic attack (TIA) and requires immediate initiation of antihypertensive therapy and comprehensive stroke workup, despite symptom resolution and negative CT scan. 1

Immediate Clinical Assessment

The spontaneous resolution of symptoms does not exclude a TIA—this presentation is classic for transient cerebral ischemia in a hypertensive patient. 1

• The combination of slurred speech, tongue deviation (cranial nerve XII involvement), and gait disturbance with complete resolution within 24 hours defines a TIA by current diagnostic criteria 1
• A negative CT scan is expected in TIA, as CT has poor sensitivity for acute ischemia and is primarily useful to exclude hemorrhage 1
• The head trauma from the fall may be coincidental or could have precipitated a hypertensive surge leading to the TIA 1

Critical Diagnostic Workup Required

MRI with diffusion-weighted imaging (DWI) is essential, as up to 30-50% of TIA patients have acute infarction on MRI despite negative CT and symptom resolution. 1

Additional mandatory investigations include:

• Vascular imaging: CT angiography or MR angiography of head and neck to assess for carotid stenosis, vertebrobasilar disease, or intracranial stenosis 1
• Cardiac evaluation: ECG, echocardiography, and prolonged cardiac monitoring (minimum 24-48 hours) to detect atrial fibrillation or other cardioembolic sources 1
• Laboratory studies: Complete blood count, metabolic panel, lipid profile, hemoglobin A1c, and coagulation studies 1
• Fundoscopy: To assess for hypertensive retinopathy and evaluate chronicity of hypertension 1

Immediate Management Protocol

Antihypertensive therapy must be initiated immediately for secondary stroke prevention—do not wait. 1

Blood Pressure Management in Acute Phase

• For TIA patients, antihypertensive treatment should be started immediately (unlike ischemic stroke where it is delayed several days) 1
• Target blood pressure <130/80 mmHg for secondary stroke prevention 1
• First-line agents include thiazide diuretics, ACE inhibitors, or ARBs, with combination therapy (thiazide plus ACE inhibitor) being particularly effective 1

Antiplatelet Therapy

Dual antiplatelet therapy (aspirin plus clopidogrel) should be initiated within 24 hours and continued for 21 days for high-risk TIA patients. 1

• This patient qualifies as high-risk given multiple neurological symptoms and known hypertension 1
• After 21 days, transition to single antiplatelet therapy (aspirin or clopidogrel) for long-term secondary prevention 1

Statin Therapy

High-intensity statin therapy should be initiated regardless of baseline lipid levels for all TIA/stroke patients. 1

Risk Stratification

This patient is at extremely high risk for completed stroke—approximately 10-20% risk within 90 days, with half occurring within the first 48 hours. 1

Key high-risk features present:

• Multiple neurological deficits (speech, cranial nerve, motor) 1
• Known hypertension (likely poorly controlled) 1
• Duration of symptoms (longer episodes carry higher risk) 1

Critical Pitfalls to Avoid

Do not be falsely reassured by symptom resolution—TIA is a medical emergency with the same urgency as acute myocardial infarction. 1

• Do not discharge without MRI and vascular imaging: CT alone misses the majority of acute ischemic lesions 1
• Do not delay antihypertensive therapy: Unlike acute ischemic stroke, TIA patients should start BP-lowering immediately 1
• Do not attribute symptoms solely to the head trauma: The neurological pattern (speech, tongue, gait) suggests vascular territory involvement, not simple concussion 1
• Do not assume "known hypertensive" means "controlled hypertensive": Verify actual BP control and medication adherence 1

Disposition and Monitoring

This patient requires hospital admission for expedited TIA workup, not outpatient evaluation. 1

• Admission allows for rapid completion of diagnostic workup within 24-48 hours 1
• Continuous cardiac monitoring to detect paroxysmal atrial fibrillation 1
• Neurology consultation for stroke risk stratification and management optimization 1
• Early carotid imaging is critical—if high-grade stenosis (>70%) is identified, urgent carotid endarterectomy or stenting within 2 weeks dramatically reduces stroke risk 1

Long-Term Secondary Prevention

Aggressive risk factor modification is mandatory and reduces recurrent stroke risk by approximately 80%. 1

• Blood pressure control: Target <130/80 mmHg with combination therapy as needed 1
• Antiplatelet therapy: Long-term single agent after initial 21-day dual therapy 1
• Statin therapy: High-intensity regardless of LDL level 1
• Diabetes management: If present, target HbA1c <7% 1
• Lifestyle modification: Smoking cessation, weight loss, exercise, Mediterranean diet 1
• Screen for secondary hypertension: Given age 40 with hypertension, consider renovascular disease, primary aldosteronism, or other secondary causes 1

The 1-year recurrent stroke risk without treatment approaches 10-15%, but with comprehensive secondary prevention measures, this risk can be reduced to 2-4%. 1