What is the most likely diagnosis and recommended acute management for a 60‑year‑old female with pre‑diabetes who presents with abrupt memory lapses and dysarthria, no focal weakness, blood pressure 160/90 mmHg, and a non‑acute CT showing chronic microvascular changes?

Acute Management of Suspected Transient Ischemic Attack (TIA)

This patient requires immediate evaluation for TIA with urgent neuroimaging, admission to a stroke unit, and initiation of antiplatelet therapy within 24 hours—this is a medical emergency with high early stroke risk that demands aggressive acute intervention, not reassurance alone. 1, 2

Why This is TIA, Not Transient Global Amnesia

The presence of dysarthria (slurred speech) is the critical distinguishing feature that makes this TIA rather than transient global amnesia (TGA). 3

• TGA produces isolated memory impairment only, with preserved motor, sensory, language, and visuospatial function 3
• TIA produces focal neurological deficits including speech disturbance, which this patient has 3, 2
• The combination of memory lapses AND dysarthria indicates multifocal cerebral ischemia, not benign TGA 3
• Misdiagnosing TIA as TGA is the most critical error because TIA patients require urgent stroke workup while TGA requires only reassurance 3

Risk Stratification: This Patient is High-Risk

Calculate the ABCD2 score to determine stroke risk: 1, 4, 2

• Age ≥60 years: 1 point 1, 4
• Blood pressure ≥140/90 mmHg: 1 point (patient has 160/90) 1, 4
• Clinical features - speech disturbance without weakness: 1 point 1, 4
• Duration: unknown from presentation 1
• Diabetes/prediabetes: 1 point 1, 4

This patient scores at minimum 4 points (high-risk), indicating she requires immediate hospital admission and aggressive intervention. 1, 2

• High-risk patients (ABCD2 ≥4) have a 3.6% stroke risk at 2 days and 11% at 7 days without urgent treatment 1
• With immediate specialized stroke center treatment, this risk drops to 0.6% at 2 days and 0.9% at 7 days 1

Immediate Diagnostic Workup (Within 24 Hours)

Neuroimaging Priority

MRI with diffusion-weighted imaging (DWI) is the preferred initial imaging modality and should be obtained within 24 hours: 2

• DWI-MRI is more sensitive than CT for detecting acute ischemic changes and has similar accuracy for excluding hemorrhage 1, 2
• The CT showing only "chronic microvascular changes" does NOT exclude acute ischemia—one-third of TIA patients have positive DWI lesions despite normal CT 1
• Positive DWI lesions (even small, multiple, asymptomatic) indicate higher recurrent stroke risk and may explain the multifocal symptoms (memory + speech) 1
• Chronic microvascular changes on CT reflect the patient's prediabetic state and increase stroke risk 5, 6, 7

Vascular Imaging

Obtain noninvasive carotid and intracranial vessel imaging urgently: 1, 2

• Carotid ultrasound or CTA to detect >50% stenosis (high-risk feature requiring possible revascularization) 1
• Intracranial vessel imaging (MRA or CTA) to identify severe stenosis or occlusion 2

Cardiac Evaluation

Perform ECG immediately and consider prolonged cardiac monitoring: 2

• Rule out atrial fibrillation (would change management to anticoagulation) 1, 2
• Echocardiography is reasonable if cardioembolic source suspected 2

Laboratory Tests

Obtain routine blood work: 1

• Complete blood count, electrolytes, renal function, glucose, lipid panel 1
• These help identify modifiable vascular risk factors and rule out stroke mimics 1

Acute Treatment (Initiate Within 24 Hours)

Antiplatelet Therapy

Start aspirin 160-300 mg daily immediately (assuming no contraindications and hemorrhage excluded): 1

• Aspirin should be commenced within 48 hours of ischemic stroke/TIA onset 1
• Do NOT withhold treatment waiting for complete workup in high-risk patients 1, 4

Blood Pressure Management

The BP of 160/90 mmHg requires careful consideration: 1

• In acute stroke/TIA, avoid aggressive BP lowering initially unless >220/120 mmHg or specific indications exist 1
• After acute phase, initiate antihypertensive therapy as part of secondary prevention 4

Statin Therapy

Initiate statin therapy urgently as part of acute TIA management: 4

• Immediate statin initiation substantially reduces 90-day stroke risk after TIA 4
• This is distinct from TGA, where statins are NOT indicated 3

Disposition

This patient requires admission to a stroke unit or specialized TIA clinic with assessment within 24 hours: 1

• High-risk patients (ABCD2 ≥4) should be admitted to facilitate rapid assessment and treatment 1
• Stroke unit care with specialized protocols reduces early stroke recurrence 1
• More frequent follow-up is required given prediabetes and microvascular disease, which predict rapid progression 1

Critical Pitfalls to Avoid

Do not dismiss this as benign TGA based on memory symptoms alone—the dysarthria indicates focal cerebral ischemia requiring urgent intervention. 3

Do not rely on the initial CT showing only chronic changes—acute ischemia may not be visible on CT, and DWI-MRI is essential. 1, 2

Do not delay treatment waiting for complete workup—antiplatelet therapy and admission should occur immediately in high-risk patients. 1, 4

Do not underestimate the vascular risk from prediabetes—this metabolic state causes significant microvascular dysfunction and increases cardiovascular disease risk independent of progression to diabetes. 5, 6, 7