What is the urgent evaluation and management for a patient who experienced a sudden transient left upper‑extremity numbness and weakness that resolved within minutes to a few hours, consistent with a transient ischemic attack?

Urgent Evaluation and Management of Transient Ischemic Attack

A patient presenting with sudden transient left upper-extremity numbness and weakness that resolved within minutes to hours requires immediate emergency department evaluation with urgent neuroimaging and vascular imaging completed within 24 hours, as this presentation places them in the very high-risk category for recurrent stroke. 1

Immediate Disposition

• Send the patient immediately to an emergency department with advanced stroke care capabilities (on-site CT/MRI, CT angiography, and access to thrombolysis/thrombectomy). 1
• Unilateral upper-extremity weakness within 48 hours of symptom onset is classified as very high risk for recurrent stroke, with historical 7-day stroke rates of 10-11% without urgent treatment, but reducible to 2.1% with immediate specialized care. 1, 2
• The highest stroke risk occurs in the first 48 hours, with half of all recurrent strokes occurring within the first 2 days. 2

Mandatory Diagnostic Workup (Complete Within 24 Hours)

Brain Imaging

• Obtain urgent brain imaging (CT or MRI) within 24 hours of presentation. 1
• MRI with diffusion-weighted imaging is preferred over CT because it detects acute infarction in approximately one-third of TIA patients, identifying those at highest risk for recurrent stroke. 2, 3
• Non-contrast CT is acceptable if MRI is unavailable and serves to exclude hemorrhage and stroke mimics. 2

Vascular Imaging

• Perform CT angiography from aortic arch to vertex immediately, ideally at the time of initial brain CT, to assess both extracranial and intracranial circulation. 1, 2
• This single study evaluates for carotid stenosis requiring urgent revascularization (which must occur within 2 weeks for maximum benefit) and intracranial large-vessel occlusion. 2
• Carotid duplex ultrasound or MR angiography are acceptable alternatives when CTA is unavailable or contraindicated. 2

Cardiac Evaluation

• Complete a 12-lead ECG without delay to identify atrial fibrillation, atrial flutter, or other cardioembolic sources. 1
• Initiate continuous cardiac monitoring for at least 24 hours to detect paroxysmal atrial fibrillation. 2

Laboratory Testing

• Draw complete blood count, basic metabolic panel, coagulation studies (aPTT, INR), renal function (creatinine/eGFR), glucose, and cardiac troponin. 2
• Lipid profile and HbA1c can be obtained during hospitalization or at outpatient follow-up. 2

Risk Stratification Framework

Very High Risk (Symptom Onset Within 48 Hours)

• Transient or persistent unilateral weakness (face, arm, leg) places patients at very high risk. 1
• These patients require immediate ED evaluation with complete diagnostic workup within 24 hours. 1
• The 7-day stroke risk without urgent treatment is 10-11%, but drops to 2.1% with immediate specialized stroke care—an 80% relative risk reduction. 1, 2

High Risk (Symptom Onset 48 Hours to 2 Weeks)

• Patients presenting 48 hours to 2 weeks after motor or speech symptoms should receive comprehensive evaluation by stroke specialists within 24 hours of first medical contact. 1

Moderate Risk (Symptom Onset 48 Hours to 2 Weeks)

• Patients with isolated sensory symptoms, monocular vision loss, diplopia, dysarthria, dysphagia, or ataxia (without motor weakness or speech disturbance) should receive evaluation within 2 weeks. 1

Critical Management Pitfalls to Avoid

• Never discharge a patient with crescendo TIAs (multiple episodes in rapid succession) under any circumstances—these patients require immediate hospitalization. 2
• Do not rely solely on ABCD² scores for disposition decisions; they supplement but do not replace comprehensive evaluation and imaging. 2, 4
• Do not delay carotid imaging in anterior circulation TIAs, as symptomatic carotid stenosis ≥50% requires urgent revascularization within 2 weeks, and the benefit declines rapidly after this window. 2
• Never discharge without confirming outpatient follow-up arrangements with a stroke specialist or rapid-access TIA clinic. 2

Hospitalization Criteria

Admit patients with any of the following:

• Acute cerebral infarction on brain imaging 2
• Large-artery atherosclerosis or symptomatic carotid stenosis >50% 2
• Cardioembolic source (atrial fibrillation, valvular disease) 2
• Crescendo TIAs (multiple episodes) 2
• Known hypercoagulable state 2
• Symptom duration >1 hour at presentation 2

Evidence Quality and Convergence

The 2018 Canadian Stroke Best Practice Recommendations provide Level A (strong) evidence that immediate evaluation in specialized stroke centers reduces stroke recurrence by approximately 80%. 1, 2 The EXPRESS and SOS-TIA trials demonstrated that rapid assessment and treatment initiation cut the 90-day stroke risk from historical rates of 10-20% down to 2-3%. 2 Multiple high-quality guidelines from 2018-2026 converge on these recommendations, with consistent evidence that patients with motor symptoms within 48 hours represent a medical emergency requiring immediate action. 1, 2