What is the appropriate management and diagnosis for a patient with transient lightheadedness, left arm weakness, and a sensation of coldness on the left side, who had a normal 12-lead electrocardiogram (EKG) and whose symptoms resolved spontaneously?

Management of Transient Focal Neurological Symptoms with Spontaneous Resolution

This patient requires urgent evaluation for transient ischemic attack (TIA) or acute limb ischemia, not simply reassurance based on symptom resolution—the combination of unilateral arm weakness and coldness demands immediate vascular and neurological assessment beyond a single normal ECG. 1

Critical Diagnostic Considerations

The clinical presentation raises two distinct but potentially overlapping vascular emergencies:

Cerebrovascular Event (TIA)

• Transient unilateral arm weakness is a classic TIA presentation and carries high risk for subsequent stroke, particularly within the first 48-72 hours 1
• The 12-lead ECG performed was appropriate as initial assessment but is insufficient to rule out cardioembolic sources or other high-risk features 2
• Serial ECGs may be necessary as high-risk abnormalities such as atrial fibrillation or QT prolongation can be intermittent 2

Acute Limb Ischemia

• The sensation of unilateral coldness combined with weakness suggests possible arterial insufficiency requiring urgent vascular assessment 3
• Acute limb ischemia can present with sensory changes (coldness, numbness) before motor weakness develops 3
• The spontaneous resolution does not exclude transient embolic or vasospastic phenomena 3

Immediate Next Steps

Mandatory Assessments

• Obtain detailed vascular examination including bilateral upper extremity pulses, capillary refill, temperature comparison, and Allen's test 3
• Document blood pressure in both arms—a difference >15 mmHg suggests subclavian stenosis or other proximal vascular pathology 4
• Perform focused neurological examination documenting any residual deficits, even if subtle 1
• Check cardiac rhythm monitoring beyond the single ECG to detect paroxysmal atrial fibrillation, which is a major cardioembolic source 2, 1

Risk Stratification for TIA

• High-risk features requiring urgent specialist evaluation include: symptoms during exertion, chest pain or palpitations preceding the event, known structural heart disease, or family history of sudden cardiac death 1
• Age >60 years (which applies here) increases risk for carotid sinus syndrome and cardiac causes 2, 1
• ABCD2 score should be calculated to stratify stroke risk, though this patient's focal motor symptoms already place them in a higher-risk category 1

Diagnostic Workup Required

Cardiovascular Assessment

• Continuous cardiac monitoring for at least 24 hours to detect arrhythmias, particularly atrial fibrillation 1
• Echocardiography to evaluate for cardioembolic sources including left atrial thrombus, patent foramen ovale, or valvular disease 2
• Carotid duplex ultrasound to assess for significant stenosis that could cause transient hemispheric symptoms 1

Vascular Assessment

• Upper extremity arterial duplex ultrasound if vascular examination reveals asymmetry or if symptoms recur 3
• Consider CT angiography of the aortic arch and upper extremity vessels if embolic source is suspected 3

Neuroimaging

• Brain MRI with diffusion-weighted imaging (DWI) is more sensitive than CT for detecting acute ischemia and should be obtained urgently 1
• CT head is acceptable if MRI unavailable, though less sensitive for small vessel territory infarcts 1

Critical Management Pitfalls to Avoid

• Do not dismiss symptoms simply because they resolved—up to 25% of TIA patients develop stroke within 90 days, with highest risk in first 48 hours 1
• Do not rely on a single normal ECG to exclude cardiac causes; paroxysmal arrhythmias require extended monitoring 2
• Do not assume vasovagal syncope given the focal neurological symptoms and unilateral coldness—this presentation is atypical for simple syncope 1, 5
• Do not delay antiplatelet therapy if TIA is confirmed and no contraindications exist—early treatment reduces stroke recurrence 2

Disposition and Follow-up

• Urgent neurology consultation within 24 hours for confirmed or suspected TIA 1
• Vascular surgery consultation if arterial insufficiency is suspected based on examination findings 3
• Admission or observation is warranted given the high-risk features rather than discharge from the emergency department 1
• Medication review to identify any drugs that could cause vasospasm or contribute to vascular symptoms 1

Special Considerations for Older Patients

• Polypharmacy-induced orthostatic hypotension can contribute to cerebral hypoperfusion, though this typically doesn't cause focal symptoms 1
• Carotid sinus hypersensitivity should be considered in patients >60 years with unexplained symptoms, though carotid sinus massage carries stroke risk and requires informed consent 2
• Autonomic dysfunction increases with age and can complicate the clinical picture 1