What is the best course of action for a 71-year-old male (M) patient with a history of hypertension, previous stroke, and current symptoms of dizziness, generalized weakness (4/5), gait swaying, and sensation of pins and needles all over the body, who is currently taking clopidogrel, aspirin, piracetam, betahistine, and flunarizine, and has normal magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) results?

Diagnostic Approach: Likely Posterior Circulation Stroke Despite Normal Initial Imaging

This 71-year-old man with progressive generalized weakness, gait ataxia, paresthesias, and hypertension most likely has an evolving posterior circulation (vertebrobasilar) ischemic stroke that was not yet visible on initial MRI/MRA, and requires urgent repeat vascular imaging, admission for continuous monitoring, and immediate dual antiplatelet therapy. 1

Critical Clinical Features Suggesting Posterior Circulation Stroke

The constellation of symptoms strongly indicates vertebrobasilar territory involvement rather than a peripheral neurological disorder:

• Gait ataxia with inability to perform tandem gait suggests cerebellar or brainstem involvement 1
• Generalized weakness (4/5) with preserved reflexes is atypical for peripheral neuropathy and more consistent with central pathology 1
• Whole-body paresthesias can occur with bilateral thalamic or brainstem lesions 1
• Progressive worsening over days (from dancing on [DATE] to unable to walk by [DATE]) indicates evolving vascular pathology 1
• History of prior stroke places him at extremely high risk for recurrent events 1

Why Initial Imaging May Be Normal

Early MRI can miss acute posterior circulation strokes in up to 20-30% of cases within the first 24-48 hours, particularly small brainstem or cerebellar infarcts. 1 The normal initial MRI/MRA does not exclude stroke—it may simply be too early to visualize the lesion. 1

Immediate Management Priorities

1. Urgent Repeat Vascular Imaging

• Obtain repeat MRI with diffusion-weighted imaging (DWI) and MRA from aortic arch to vertex immediately 1, 2
• If MRI unavailable, CT/CTA is acceptable but less sensitive for posterior fossa lesions 1
• Look specifically for vertebrobasilar stenosis, basilar artery occlusion, or cerebellar infarction 1

2. Blood Pressure Management

Do NOT aggressively lower blood pressure in this patient. 1, 3

• Current blood pressure should be maintained unless >220/120 mmHg 1, 3
• In acute ischemic stroke, aggressive BP reduction can worsen cerebral perfusion and expand infarct size 1, 3
• Target: Allow permissive hypertension with systolic BP <220 mmHg and diastolic <120 mmHg 1, 3
• After stabilization (24-48 hours), gradually reduce to <140/90 mmHg over days to weeks 1, 3

3. Antiplatelet Therapy

Initiate dual antiplatelet therapy immediately if imaging confirms stroke/TIA within 24 hours of symptom onset: 1

• Aspirin 160-325 mg loading dose PLUS clopidogrel 300-600 mg loading dose 1
• Continue aspirin 81 mg daily + clopidogrel 75 mg daily for 21-90 days 1
• After 21-90 days, transition to single antiplatelet agent (clopidogrel 75 mg daily preferred) 1

Critical timing consideration: The patient is already on aspirin and clopidogrel, but dosing and compliance should be verified. If he has been compliant and symptoms are still progressing, this suggests either inadequate antiplatelet effect or a different mechanism. 1, 4

4. Discontinue or Reassess Non-Evidence-Based Medications

The current regimen includes medications with questionable benefit:

• Piracetam: No established benefit for stroke prevention; consider discontinuation 5
• Betahistine: Indicated for vertigo, not stroke prevention; reassess need 5
• Flunarizine: Calcium channel blocker with limited stroke prevention evidence; consider switching to evidence-based antihypertensive 1

Diagnostic Workup

Laboratory Evaluation

• Complete blood count, platelets (assess for thrombocytopenia or polycythemia) 2
• Comprehensive metabolic panel (creatinine, electrolytes, glucose) 2
• Lipid panel (for statin therapy optimization) 1
• Hemoglobin A1c (assess diabetes control) 1
• Coagulation studies if considering anticoagulation 1

Cardiac Evaluation

• 12-lead ECG to assess for atrial fibrillation (would change management to anticoagulation) 1
• Echocardiogram to evaluate for cardioembolic source 1
• Continuous cardiac monitoring for at least 24-48 hours to detect paroxysmal atrial fibrillation 1

Vascular Assessment

• Carotid duplex ultrasound to assess for extracranial stenosis 1
• Transcranial Doppler if available to assess intracranial flow dynamics 1

Risk Factor Optimization

1. Statin Therapy

Initiate or intensify high-intensity statin therapy immediately: 1

• Atorvastatin 80 mg daily OR rosuvastatin 20-40 mg daily 1
• Target LDL <70 mg/dL (1.8 mmol/L) 1
• Do not wait for lipid panel results—start empirically 1

2. Blood Pressure Control (After Acute Phase)

After 24-48 hours of stabilization, initiate or optimize antihypertensive therapy: 1

• Target: <140/90 mmHg (or <130/80 mmHg if tolerated) 1
• First-line agents: ACE inhibitor or ARB + thiazide diuretic 1
• Example regimen: Lisinopril 10-40 mg daily + hydrochlorothiazide 12.5-25 mg daily 1
• Avoid rapid titration—achieve target over weeks 1, 3

3. Glucose Control

• If diabetic, optimize glycemic control with target HbA1c <7% 1
• Avoid hypoglycemia, which can mimic stroke symptoms 1

Admission and Monitoring

This patient requires hospital admission, preferably to a stroke unit or ICU: 1, 2

• Continuous neurological monitoring (Glasgow Coma Scale, focal deficits) 1, 2
• Vital signs every 2-4 hours (BP, heart rate, oxygen saturation, temperature) 1, 2
• Swallowing assessment before oral intake to prevent aspiration 1
• Early mobilization and physical therapy once stable 1

Critical Pitfalls to Avoid

1. Do not dismiss normal initial imaging—posterior circulation strokes frequently have delayed MRI findings 1, 2
2. Do not aggressively lower blood pressure acutely—this can worsen cerebral perfusion and expand infarct 1, 3
3. Do not delay antiplatelet therapy—early initiation (within 24-48 hours) significantly reduces recurrent stroke risk 1
4. Do not use triple therapy (aspirin + clopidogrel + anticoagulation) unless absolutely indicated, as bleeding risk is prohibitive 1
5. Do not overlook atrial fibrillation—if present, anticoagulation is superior to antiplatelet therapy 1
6. Do not continue non-evidence-based medications (piracetam, betahistine) that may give false reassurance without proven benefit 5

If Vertebrobasilar Stenosis Is Confirmed

Medical management is strongly preferred over endovascular intervention: 1

• Dual antiplatelet therapy (aspirin + clopidogrel) for 21-90 days 1
• High-intensity statin therapy 1
• Blood pressure control to <140/90 mmHg 1
• Angioplasty/stenting is NOT recommended as first-line therapy due to high complication rates 1

Follow-Up Strategy

• Repeat vascular imaging in 3-6 months to assess progression of atherosclerotic disease 1
• Outpatient neurology follow-up within 1-2 weeks after discharge 1
• Monthly blood pressure checks until target achieved 1
• Lipid panel at 4-6 weeks to assess statin efficacy 1
• Screen for secondary causes of stroke (hypercoagulable states, vasculitis) if no clear etiology identified 1, 2