TIA

Question 1

Define TIA [1]

Answer 1

caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.

Question 2

Numerous conditions can present similarly to TIA, which are collectively referred to as ‘stroke mimics’.

What are these? [+]

Answer 2

Toxic/metabolic: hypoglycaemia, drug and alcohol consumption
Neurological: seizure, migraine, Bell’s palsy
Space occupying lesion: tumour, haematoma
Infection: meningitis/encephalitis, systemic infection with ‘decompensation’ of old stroke
Syncope: extremely uncommon presentation of TIA, many causes

Question 3

Why is TIA a medical emergency? [1]

Answer 3

10% of untreated TIA will go onto have a stroke in 1 month

Question 4

Describe the acute and long term managment of a TIA [+]

Answer 4

Acute treatment:
Any patient with a suspected TIA should be treated with 300 mg of aspirin unless contraindicated.

Patients with atrial fibrillation or significant carotid artery disease require a different treatment pathway:
- Atrial fibrillation (AF): should be offered and counselled about starting an oral anticoagulant
- Carotid artery disease (CAD): urgent referral for consideration of carotid endarterectomy if significant disease. Based on NASCET or ECST criteria for stenosis.

For patients within 24 hours of onset of TIA or minor ischaemic stroke and with a low risk of bleeding, the following DAPT regimes should be considered:
* clopidogrel (initial dose 300 mg followed by 75 mg od) + aspirin (initial dose 300 mg followed by 75 mg od for 21 days) followed by monotherapy with clopidogrel 75 mg od
- ticagrelor + clopidogrel is an alternative
- if not appropriate for DAPT:
clopidogrel 300 mg loading dose followed by 75 mg od should be given

Refer to TIA clinic ASAP (Carotid imaging within 24hrs)

Secondary Prevention:
* Anti-hypertensives: as per hypertension guidelines (tolerate higher if significant bilateral CAD)
* Lipid modification: offer high-dose statin therapy unless contraindication.
* Diabetic control: treat any new diagnosis of diabetes and optimise control of pre-existing disease
* Obstructive sleep apnoea: referral to specialist sleep medicine/respiratory clinic if suspected
* Pre-menopause: use of combined oral contraceptive pill contraindicated.

Question 5

Describe the TIA management plans depending if in A&E – DGH? [4]

Answer 5

⚫ CT
⚫ ECG
⚫ Start Antiplatelets
⚫ Refer to TIA clinic ASAP (Carotid imaging within 24hrs)

Question 6

Describe the TIA management plans depending if in A&E – HASU? [5]

Answer 6

⚫ CT
⚫ ECG
⚫ Start Antiplatelets
⚫ CTA/Doppler
⚫ Refer to TIA clinic

Question 7

When would you admit a patient with TIAs? [3]

Answer 7

⚫ Anticoagulation.
⚫ Carotid surgery
⚫ Crescendo TIAs

Question 9

Steriotyped repeat attacks

Answer 9

Carotid artery caused TIAs?

Question 10

What impact does stroke have on driving? [2]

Answer 10

Cars and motorcycles:
- stop driving one month. Inform DVLA if ongoing symptoms after one month

Larger vehicles
- (e.g. buses, lorries): stop driving, inform the DVLA

Question 11

Examples of TIA mimics that require exclusion? [2]

Answer 11

hypoglycaemia
intracranial haemorrhage