What is the appropriate urgent evaluation and management for an adult patient with a recent transient ischemic attack who now presents with left eyelid ptosis, right‑sided headache, and a National Institutes of Health Stroke Scale (NIHSS) score of 1?

Urgent Evaluation for Possible Carotid Dissection or Evolving Stroke

This patient requires immediate hospitalization and urgent vascular imaging to rule out carotid artery dissection—the combination of left eyelid ptosis (Horner syndrome) with contralateral headache in a recent TIA patient is a red flag for arterial dissection, which carries extremely high stroke risk. 1

Why This Patient Cannot Be Managed as a Simple TIA Return Visit

Critical Warning Signs Present

• Left eyelid ptosis with right-sided headache suggests ipsilateral carotid dissection with referred pain, a surgical emergency that can progress to complete stroke within hours 1
• Recent TIA diagnosis means this patient is already in the highest-risk window (10% stroke risk at 7 days without urgent treatment) 2, 3
• NIHSS of 1 indicates active neurological deficit, not a resolved TIA—this is technically a minor stroke requiring immediate workup 1
• Headache in 30% of TIA patients, particularly ipsilateral headache, often precedes arterial occlusion and indicates unstable vascular pathology 4

Mandatory Immediate Actions in the Emergency Department

Complete the following within 24 hours of arrival: 1, 2

1. Brain MRI with diffusion-weighted imaging (DWI) to detect acute infarction—up to 31% of TIA patients have silent cerebral infarctions that dramatically increase stroke recurrence risk 1, 2

2. CT angiography from aortic arch to vertex immediately to evaluate for carotid dissection, which presents with Horner syndrome (ptosis, miosis, anhidrosis) plus headache 1, 2, 5

   • If CTA unavailable, obtain carotid duplex ultrasound with transcranial Doppler urgently 1, 2
   • MR angiography is acceptable alternative if CTA contraindicated 1, 2

3. 12-lead ECG immediately to identify atrial fibrillation or other cardioembolic sources 1, 2

4. Laboratory workup: complete blood count, electrolytes, creatinine, glucose, lipid panel, coagulation studies (PT/PTT), ESR and CRP if age >50 years to exclude giant cell arteritis 1

5. Prolonged cardiac monitoring (inpatient telemetry minimum 24 hours) given unclear etiology after initial TIA 1, 2

Why Hospitalization Is Mandatory for This Patient

This patient meets multiple absolute criteria for admission: 1, 5

• First TIA within past 24-48 hours (or recent diagnosis suggesting this timeframe) 1, 5
• New neurological symptoms (ptosis) with NIHSS score of 1 indicating active deficit 1
• Possible symptomatic carotid stenosis or dissection requiring urgent identification 1, 5
• Crescendo pattern if multiple symptoms developing (ptosis now, TIA recently) 1, 5

Stroke Risk Without Urgent Treatment

• 1.5% stroke risk at 2 days, 2.1% at 7 days with specialized stroke center care 2, 3, 6
• Up to 10-11% stroke risk at 7 days in population-based studies without urgent treatment 2, 3, 6
• 20.1% stroke risk at 90 days if symptomatic carotid stenosis >50% is present 2, 3
• Half of all recurrent strokes occur within first 48 hours after TIA 2, 3

Differential Diagnosis for Left Ptosis with Right Headache

Most Likely: Carotid Artery Dissection

• Horner syndrome (ptosis, miosis, anhidrosis) ipsilateral to dissection with contralateral or ipsilateral headache is classic presentation 1
• Requires immediate anticoagulation or antiplatelet therapy once hemorrhage excluded 1, 2
• May require urgent endovascular intervention if progressing 1, 2

Alternative Considerations

• Posterior circulation stroke affecting oculomotor pathways with referred headache 4
• Vertebrobasilar TIA (headache more common in posterior circulation, 30% of TIA patients have headache) 4
• Lacunar infarction in brainstem affecting sympathetic pathways 4, 7

Critical Pitfalls to Avoid

• Never discharge a patient with new neurological symptoms after recent TIA—this represents either stroke-in-evolution or crescendo TIA pattern requiring immediate hospitalization 1, 5
• Do not rely on NIHSS score of 1 to minimize urgency—even minor deficits after TIA indicate tissue-based injury with 20-times higher early stroke risk 7
• Do not delay vascular imaging to "complete outpatient workup"—carotid dissection can progress to complete occlusion within hours 1
• Do not assume resolved TIA symptoms mean low risk—33.4% of TIA patients have acute brain infarction on DWI-MRI despite symptom resolution 6, 7

Immediate Treatment Pending Imaging Results

Start immediately upon ED arrival: 1, 2, 5

• Aspirin 325 mg loading dose (if not already on antiplatelet therapy and no contraindications) 1, 2
• High-intensity statin (atorvastatin 80 mg or rosuvastatin 40 mg) regardless of baseline lipid levels 2, 5
• Blood pressure optimization (permissive hypertension initially unless >220/120 mmHg) 2, 5
• NPO status until swallow evaluation completed 1

Expected Timeline for Definitive Management

• Carotid endarterectomy within 2 weeks if symptomatic stenosis 70-99% identified (benefit diminishes rapidly after 2 weeks) 1, 2, 3
• Carotid endarterectomy may be beneficial for symptomatic stenosis 50-69% in select patients at experienced centers with <6% complication rate 1
• Anticoagulation initiation if cardioembolic source (atrial fibrillation) or carotid dissection confirmed 1, 2