Management of Weakness and Vertigo in Patients with Prior Stroke History

Risk Stratification and Urgency

A patient with a history of stroke presenting with new weakness and vertigo is at very high risk for recurrent stroke and requires immediate emergency department evaluation with urgent neuroimaging, as this presentation indicates very high risk for recurrent stroke and demands assessment within 24 hours 1, 2, 3
The combination of weakness and vertigo places the patient in the highest risk category, suggesting possible posterior circulation involvement and increasing stroke risk 1, 2, 3
Patients with symptoms started within the last 48 hours are at very high risk for recurrent stroke and should be immediately sent to an emergency department with capacity for advanced stroke care 1, 2, 3, 4, 5
The American Heart Association recommends that patients with symptoms started between 48 hours and 2 weeks ago should receive comprehensive clinical evaluation and investigations by a healthcare professional with stroke expertise as soon as possible, ideally within 24 hours of first contact 1, 2, 3

Urgent brain imaging (CT or MRI) should be completed as soon as possible within 24 hours for patients presenting within 48 hours 1, 2, 3
Noninvasive vascular imaging (CTA or MRA from aortic arch to vertex) should be completed within 24 hours for patients presenting within 48 hours 1, 2, 3
An electrocardiogram should be completed without delay for patients presenting with weakness and vertigo 1, 2, 3
A 12-lead ECG to evaluate for atrial fibrillation or other cardiac sources of embolism should be performed 1, 2, 3

The patient should be transferred immediately to an ED with advanced stroke care capabilities (brain and vascular imaging on site, access to thrombolysis/endovascular therapy) 1, 4, 5
Extracranial vascular imaging is essential to identify extracranial carotid stenosis for which patients should be referred for possible carotid revascularization 4
The risk of recurrent stroke is highest in the first 48 hours and first week after symptom onset, and delay in evaluation should be avoided 5, 6