ACH - TIA

Question 1

If suspecting a TIA, how long must symptoms have lasted for?

Answer 1

< 24 hrs

Note: often TIA symptoms only last several minutes but can extend to hours or almost the full 24h period

Question 2

Which of the following symptom descriptions are likely to be due to a TIA:

• Neurological impairment that spreads from one part of the body to another
• Impairment moving from one modality to another e.g. visual disturbance to tingling of a limb
• Symptoms come on gradually

Answer 2

NONE OF THEM!

These are all indications that it is unlikely to be a TIA!

Question 3

What scoring system can be used to estimate the risk of stroke after a suspected TIA? And what elements are involved?

Answer 3

ABCD² score

(no longer NICE reccomended for community assessment)

Score is out of 7 (0-3 low risk, 4-5 moderate, 6-7 high)

• Age > 60 yrs (+1)
• SBP > 140 or DBP > 90 (+1)
• Clinical features of TIA:
  
  • Other symptoms (+0)
  • Speech disturbance without weakness (+1)
  • Unilateral weakness (+2)
• Duration of symptoms:
  
  • < 10 mins (+0)
  • 10-59 mins (+1)
  • > 60 mins (+2)
• Hx of Diabetes (+1)

Question 4

How quickly do patients with a suspected TIA in GP need to be seen in hospital?

Answer 4

Suspected TIA = referred for 8:30AM assessment on the morning after being seen at the GP

Question 5

What is a crescendo TIA?

Answer 5

> 2 episodes of TIA within a week - needs urgent specialist evaluation

Question 6

What conditions can mimic signs of a TIA?

These conditions can often be differentiated by the history.

Answer 6

• Syncope - although TIA does not usually cause TLoC
• Atypical seizures - often repetitive and sterotypical + post ictal period
  
  • Todd paresis = occasionally following a seizure a pt can develop unilateral weakness
• Migraine - often unilateral headache, photophobia, Hx of migraine, aura
• Temporal arteritis - TA tenderness, jaw claudication, visual impairment
• Retinal haemorrhage or detatchment - unilateral vision loss / spots (goes away if patient closes that eye
• Hypoglycaemia - can cause neurological disturbances (check for gliclazide or insulin)
• Labyrinthine disorders /w vertigo - can be confused for posterior circulation TIA, BPPV occurs when moving head + is recurrent and curable with Epley manoeuvre

Question 7

When a referred TIA pt is seen in clinic, what 5 investigations from this list should be done?

• MRI brain
• CT brain
• Calf US
• Blood tests: FBC, U+Es, LFT, lipids
• Carotid artery doppler
• Blood glucose
• 24h blood pressure monitor
• Height, weight and BMI
• Echocardiogram
• ECG

Answer 7

1. Blood tests
2. Carotid artery doppler
3. Blood glucose
4. Height, weight and BMI
5. ECG

Note: MRI / CT brain is only recommended if the diagnosis is uncertain i.e. features not typical of TIA (clinics which can will often MRI pts anyway e.g. Wythenshawe)

Question 8

If you have a patient with AF, what tool allows you to:

1. Calculate the risk of stroke
2. Calculate the reduction in risk with anti-platelets and anticoagulants + risk of bleeding with these meds

Answer 8

SPARC tool

• You input answers to both CHADVASc + HAS-BLED
• Provides annual risk of stroke without medication and for a variety of medications
• Provides annual risk of major bleeding (e.g. ICH, bleeding requiring hospital) for each medication

Question 9

After a TIA what medications might you consider giving to a patient?

Answer 9

1. Aspirin 300mg daily for 2 weeks
2. If Atrial fibrillation + stroke or TIA:
   
   • Pt seen in anticoagulation clinic after 2 weeks - Warfarin or Xa inhibitor (e.g. apixaban)
3. If HTN:
   
   • See HTN pathway for meds
   • BP target 130/80 mmHg
4. If total cholesterol high or cholesterol ratio (total/HDL) is high:
   
   • Statin e.g. Simvastatin 40mg

Question 10

What type of medication is the mainstay of stroke/TIA risk factor reduction?

How does this change if the pt has AF?

Answer 10

Main treatments = anti-platelets e.g. aspirin or clopidogrel

If pt has AF = anticoagulation e.g. warfarin or Xa inhibitor (apixaban)

Question 11

What is the initial management of a suspected TIA in a patient seen in the community?

Answer 11

1. Aspirin 300mg immediately then DAILY for 2-weeks unless:
   
   • Pt has a bleeding disorder or is taking an anticoagulent (if so, then immediate admission for imaging to exclude haemorrhage)
   • Pt already on low-dose aspirin
   • Aspirin is contraindicated
2. Refer immediately for specialist assessment within 24hrs
   
   • If pt has had > 1 TIA in short time or suspected cardioembolic source then discuss need for urgent admission
   • ​If pt has had suspected TIA > 7 days ago then refer to specialist asap within next 7 days

Question 12

Should brain imaging be done for suspected TIA?

If so, what?

Answer 12

NO!!

CT-brain or MRI-brain are to be done if there is clinical suspicion of an alternative diagnosis that either scan would detect

Question 13

What long term management would you consider for a TIA patient?

Answer 13

1. Clopidogrel = 1st line (same as stroke), start after 2-weeks of aspirin 300mg
2. Aspirin + dipyridamole (if can’t tolerate clopidogrel)
3. Carotid endarterectomy IF:
   
   1. Pt suffered stroke/TIA in the carotid territory (consider biological diversity e.g. posterior cerebral artery coming off carotid) + not severly disabled
   2. Only considered if stenosis > 70% (ECST criteria) or > 50% (NASCET criteria)