A 52-year-old right-handed woman comes to the emergency department due to speech arrest and right arm weakness. The symptoms began suddenly at breakfast but resolved after about 30 minutes. The patient has a history of relapsing-remitting multiple sclerosis. Three months ago, she was hospitalized due to blurry vision in the left eye, which was treated with corticosteroids and improved after several weeks. The patient's other medical issues include hypertension and hyperlipidemia. She is currently not taking any disease-modifying therapy for her multiple sclerosis. She has a 40-pack-year history of tobacco use. Blood pressure is 170/96 mm Hg, and pulse is 92/min. BMI is 35 kg/m². There is a mild afferent pupillary defect in the left eye with diminished visual acuity. Noncontrast CT scan of the head is unremarkable. Which of the following is the best next step in treatment of this patient?

Question

Quizplus · Accepted Answer

This patient with sudden-onset speech arrest and right arm weakness that resolved after 30 minutes along with an unremarkable noncontrast CT scan of the head likely had a transient ischemic attack (TIA) in the left middle cerebral artery blood supply distribution. In patients with multiple sclerosis (MS), new focal neurological symptoms may not always be due to an acute MS attack. Neurological deficits related to an acute demyelinating plaque of MS usually last for days to weeks; in contrast, transient symptoms lasting for <24 hours in a patient with multiple vascular risk factors (eg, hypertension, hyperlipidemia, tobacco use) are much more suggestive of TIA. TIAs are treated by modifying identifiable risk factors to prevent recurrent TIA or stroke, including discontinuing tobacco use, initiating aspirin, starting a statin for hyperlipidemia, and reducing blood pressure. (Choices A, B, E, and G) Intravenous glucocorticoids, immunoglobulins, and plasma exchange therapy can all be used to treat an acute MS exacerbation. This patient with evidence of optic neuritis (eg, afferent pupillary defect) may eventually need a disease-modifying agent (eg, interferon beta, glatiramer) to slow the progression of her relapsing-remitting MS. However, in the immediate setting, management should focus on this patient's transient symptoms, which are more suggestive of TIA. (Choice C) Administration of tissue plasminogen activator is used for the treatment of acute ischemic stroke that causes a significant neurological deficit (eg, hemiparesis) and presents within 4.5 hours from onset of symptoms. This patient's focal neurological symptoms have resolved, making a stroke unlikely. (Choice F) An intravenous heparin infusion is infrequently used for the treatment of acute ischemic stroke unless other clear indications are found as the cause (eg, atrial fibrillation, vascular dissection). Educational objective: Neurological deficits related to an acute demyelinating plaque of multiple sclerosis usually last for days to weeks whereas transient ischemic attack (TIA) symptoms usually last for <24 hours. The initial treatment of TIA is modifying risk factors, starting aspirin and statin, and improving blood pressure control. References: Transient ischaemic attacks: mimics and chameleons. (http://www.ncbi.nlm.nih.gov/pubmed/24453269) Differentiation of true transient ischemic attack versus transient ischemic attack mimics. (http://www.ncbi.nlm.nih.gov/pubmed/25422730)

A 52-Year-Old Right-Handed Woman Comes to the Emergency Department Due