Transient Ischaemic Attack

Question 1

What was the original definition of TIA?

Answer 1

A sudden onset of focal neurological symptoms and/or signs lasting less than 24 hours brought on by transient decrease in blood flow

Question 2

What is the new definition of TIA?

Answer 2

A transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without acute infarction.

Question 3

What score can be used to predict stroke after having a TIA?

Answer 3

ABCD2 score
Age more than 60 = 1
BP > 140/90 =1
Clinical features - unilateral weakness = 2, speech disturbance without weakness = 1
Duration of symptoms > 60minutes = 2, 10-60 = 1, less than 10 = 0
Diabetes = 1

0-3 = 1%
4-5 = 4%
6-7= 8% 

If more than or equal to 4 = high risk

Question 4

The ABCD2 was previously used to risk stratify, but NICE recommends:

Answer 4

300mg aspirin immediately unless :

1) bleeding disorder or taking an anticoagulant - needs admitting for imaging to exclude haemorrhage
2) already taking low dose aspirin regularly - continue until reviewed by specialist
3) Aspirin is contraindicated

Question 5

If the patient has had more than 1 TIA, or suspected cardioembolic source or severe carotid stenosis, what should be done?

Answer 5

Discuss need for admission or observation urgently with stroke specialist

Question 6

What should be done if patient has had TIA in last 7 days?

Answer 6

Urgent assessment within 24 hours by specialist stroke physician

Question 7

If a patient has had a suspected TIA which occurred more than a week previously, what should be done?

Answer 7

Referral for specialist assessment as soon as possible, within 7 days

Question 8

If patient has had a suspected TIA can they drive?

Answer 8

Not until seen by specialist

Have to stop driving for 1 month following a TIA

Question 9

Is there infarction to brain tissue in a TIA ?

Answer 9

No

Question 10

Are CT changes seen in a TIA?

Answer 10

No

Question 11

When should carotid endarterectomy be considered?

Answer 11

If stenosis > 70%

Question 12

Without intervention, more than how many people will go on to have a stroke?

Answer 12

1 in 12 within a week , so prompt management important

Question 13

What happens when the retinal artery is occluded?

Answer 13

Amaurosis fugax - causing unilateral progressive vision loss
Like a curtain descending

Question 14

Are global events e.g syncope or dizziness typical of TIAs?

Answer 14

No

Question 15

What do multiple, highly stereotyped attacks (crescendo TIAs) suggest?

Answer 15

A critical intracranial stenosis - commonly the superior division of MCA

Question 16

What are the causes?

Answer 16

Atheroembolisation from carotids = chief cause
Cardioembolisation - AF, mural thrombus post MI, valve disease, prosthetic valve
Hyperviscosity - polycythemia, Sickle cell anaemia, myeloma
Vasculitis - SLE, PAN, syphilis

Question 17

What are some differentials?

Answer 17

Hypoglycaemia
Migraine aura
Focal epilepsy
Retinal bleeds

Rare mimics: malignant HTN, MS (paroxysmal dysarthria), intracranial tumours, peripheral neuropathy

Question 18

What tests should be done?

Answer 18

FBC, ESR, U&E, lipids
CXR
ECG 
Carotid Doppler +/- angiography 
CT or diffusion weighted MRI 
ECHO

Question 19

What further management should be done?

Answer 19

After giving aspirin 300mg for 2 weeks switch to clopidogrel 75mg OD
- if clopidogrel not tolerated give aspirin 75mg OD combined with slow release dipyridamole

Control BP - aim less than 140/90
Control lipids, DM, help to stop smoking
Anticoagulation indications if cardiac cause - DOAC or warfarin
Carotid endarterectomy if indicated

Question 20

Following a single TIA when can patent start driving again?

Answer 20

If symptom free after 1 month - no need to inform DVLA

Question 21

If patient has multiple TIAs over short period, what should they do with regards to driving?

Answer 21

3 months off driving and inform DVLA