In a patient with recent transient perioral numbness that has resolved and labile blood pressure, is a non‑contrast computed tomography (CT) head indicated?

CT Head is Justified in This Clinical Scenario

In a patient with recent transient perioral numbness (now resolved) and labile blood pressure, non-contrast CT head is usually appropriate as initial imaging to exclude acute stroke, intracerebral hemorrhage, or other intracranial pathology. 1

Clinical Reasoning

This Presentation Meets Criteria for TIA Evaluation

• Transient perioral numbness represents a focal neurologic deficit, which is the strongest predictor of positive head CT findings (adjusted odds ratio 20.7) in non-trauma emergency patients 2
• Even though symptoms have resolved, this clinical picture is consistent with a transient ischemic attack (TIA), which carries an 8.8% risk of stroke at 7 days and 11.6% at 90 days 1
• The ACR Appropriateness Criteria designate CT head without IV contrast as "usually appropriate" for initial imaging in patients with clinical TIA and resolved symptoms 1

Labile Blood Pressure Adds Additional Concern

• Labile blood pressure in the context of acute neurologic symptoms raises concern for:
  • Hypertensive intracerebral hemorrhage, for which non-contrast CT is essential for diagnosis 1
  • Posterior reversible encephalopathy syndrome (PRES)
  • Acute ischemic stroke with secondary blood pressure dysregulation
• Non-contrast CT head is the primary modality to rapidly exclude hemorrhage in this setting 1

Imaging Algorithm

Initial Imaging (Perform Immediately)

• Non-contrast CT head is the first-line examination 1
  • Rapidly excludes hemorrhage 1
  • Identifies early ischemic changes 3
  • Can detect venous sinus thrombosis (sensitivity 100%, specificity 83%) 4
  • Attenuation measurements >64 HU in venous sinuses suggest thrombosis 4

Consider Additional Vascular Imaging

• CTA head and neck should be strongly considered as part of the initial workup 1
  • The evaluation of TIA requires rapid vascular imaging of cervical carotid arteries 1
  • Risk of stroke following carotid territory TIA correlates directly with degree of stenosis (20.1% at 90 days with symptomatic carotid disease) 1
  • CTA can be performed rapidly, often concurrent with non-contrast CT 1

Key Clinical Pitfalls

• Do not be falsely reassured by symptom resolution – TIA carries substantial short-term stroke risk despite complete clinical recovery 1
• Perioral numbness is a focal neurologic deficit, not a benign sensory symptom – it warrants the same urgent evaluation as other focal deficits 2
• Normal initial CT does not exclude TIA or early ischemic stroke – early ischemic changes can be subtle and require experience to detect 3
• The combination of focal neurologic symptoms plus labile blood pressure creates a high-risk clinical scenario requiring imaging regardless of symptom resolution 1, 2

Contraindications to Delaying Imaging

• Age >55 years (adjusted OR 3.08 for positive findings) 2
• Any additional risk factors: altered mental status, nausea/vomiting, known malignancy, or coagulopathy 2
• In the proposed clinical scoring algorithm, focal neurologic deficit alone (which this patient has) is sufficient to warrant CT imaging 2