What is the diagnosis and management for a 53-year-old female with intermittent sensory disturbances and paresthesia (abnormal sensations) on the right side of her face, arm, and upper thigh, along with left hand and arm weakness, episodes of trembling, and decreased ability to grasp?

Diagnosis: Transient Ischemic Attack (TIA) or Stroke from Carotid Artery Disease

This 53-year-old woman presenting with intermittent right-sided sensory disturbances (face, arm, upper thigh) and contralateral left arm weakness with trembling episodes is most consistent with cerebrovascular disease, specifically TIA or stroke from carotid stenosis, and requires urgent neurological evaluation and vascular imaging within 24 hours. 1

Clinical Reasoning for Cerebrovascular Etiology

• The combination of right-sided sensory symptoms affecting face, arm, and upper thigh represents a classic anterior circulation distribution, suggesting involvement of the middle cerebral artery territory supplied by the internal carotid artery 1

• Contralateral left arm weakness with decreased grasp and trembling episodes could represent either:

  • A separate vascular event in the opposite hemisphere 1
  • "Limb-shaking TIA" from hemodynamic impairment due to severe carotid stenosis, which manifests as positive motor phenomena (trembling) rather than pure weakness 1

• The intermittent nature of symptoms is pathognomonic for TIA, where focal neurological deficits typically last less than 60 minutes but can recur 1

• Motor deficits (isolated hand/arm weakness), sensory deficits, or their combination are classic manifestations of carotid-related cerebral ischemia from athero-thromboembolism 1

Urgent Diagnostic Workup Required

Immediate Vascular Imaging (Within 24 Hours)

• Carotid duplex ultrasound to assess for carotid stenosis, as carotid stenosis >50% is the strongest predictor of new vascular events after TIA 1

• CT or MRI brain to exclude acute stroke, hemorrhage, or alternative structural lesions 1

• CT angiography or MR angiography of head and neck vessels to evaluate degree of stenosis and plaque morphology 1

Risk Stratification

• Patients with TIA from carotid stenosis face up to 6% stroke risk in the first year, making urgent evaluation critical 1

• Plaque features suggesting high stroke risk include echolucency on ultrasound, ulcerations, and intraplaque hemorrhage 1

Alternative Diagnoses to Exclude

Guillain-Barré Syndrome (Less Likely)

• GBS is unlikely because:

  • The patient has asymmetric symptoms (right sensory, left motor), whereas GBS typically presents with bilateral ascending symmetric weakness 2, 3
  • Marked persistent asymmetry is a red flag that should prompt reconsideration of GBS diagnosis 2
  • The intermittent nature does not fit GBS, which has progressive symptoms over days to 4 weeks without remission 2
  • No mention of diminished or absent reflexes, which is a key diagnostic feature of GBS 2

• However, if neurological examination reveals bilateral weakness with areflexia, consider GBS and perform:

  • Lumbar puncture looking for albumino-cytological dissociation 2
  • Electrodiagnostic studies showing sensorimotor polyradiculoneuropathy with "sural sparing pattern" 2
  • Serial vital capacity measurements to assess respiratory function 2

Multiple Sclerosis (Possible but Less Likely)

• MS can present with paroxysmal attacks of facial paresthesia and unilateral hand tremor 4

• However, the age of onset (53 years) and lack of relapsing-remitting pattern make MS less likely than cerebrovascular disease in this age group 4

• If considering MS, obtain MRI brain and spine with contrast looking for periventricular white matter lesions and spinal cord involvement 4

Peripheral Neuropathy or Entrapment (Unlikely)

• The distribution involving face, arm, and thigh cannot be explained by a single peripheral nerve or nerve root 5, 6

• Carpal tunnel syndrome would not explain facial sensory symptoms or upper thigh involvement 6

Management Algorithm

Step 1: Immediate Assessment (Emergency Department)

• NIHSS (NIH Stroke Scale) to quantify neurological deficit 7

• Vital signs and cardiac monitoring for arrhythmias (atrial fibrillation) 1

• Blood glucose to exclude hypoglycemia as a stroke mimic 2

Step 2: Imaging Within 24 Hours

• Non-contrast CT head immediately to exclude hemorrhage 1

• Carotid duplex ultrasound or CT angiography of neck vessels 1

• MRI brain with diffusion-weighted imaging (more sensitive than CT for acute ischemia) 1

Step 3: Secondary Prevention

• Dual antiplatelet therapy (aspirin plus clopidogrel) for 21 days if TIA confirmed, then single agent 1

• High-intensity statin regardless of baseline cholesterol 1

• Blood pressure management with target <140/90 mmHg 1

• Carotid revascularization (endarterectomy or stenting) if stenosis ≥50% with symptoms, ideally within 2 weeks of symptom onset 1

Critical Pitfalls to Avoid

• Do not dismiss intermittent symptoms as "functional" – TIA is a medical emergency with high short-term stroke risk 1

• Do not delay imaging waiting for symptoms to recur – absence of symptoms at time of evaluation does not exclude TIA 1

• Do not attribute bilateral symptoms to a single lesion without imaging – this patient may have bilateral carotid disease or multiple embolic events 1

• Do not confuse "limb-shaking TIA" with seizure – trembling from hemodynamic impairment is a recognized stroke mechanism requiring urgent revascularization 1