TIA

Question 1

What is a transient ischaemic attack?

Answer 1

An ischaemic neurological event with symptoms lasting <24hrs (often much shorter)

Question 2

What are the signs of TIA?

Answer 2

Specific to the arterial territory involved

Attacks might be single or multiple highly stereotyped

Question 3

Describe amaurosis fugax

Answer 3

Occurs when the retinal artery is occluded, causing unilateral progressive vision loss like a curtain descending

Question 4

Describe the TIA which suggests critical intracranial stenosis

Answer 4

Multiple highly stereotyped attacks (crescendo TIA)

Question 5

List the causes of TIA

Answer 5

Atherothromboembolism - from the carotid
Cardio embolism - mural thrombus post MI or AF, valve disease and prosthetic valves
Vasculitis

Question 6

What is a sign of Atherothromboembolism in the carotid

Answer 6

Bruit

Question 7

List some rare TIA mimics

Answer 7

Malignant hypertension
MS
Intracranial tumours
Peripheral neuropathy 
Pheochromocytoma
Somatization

Question 8

List some TIA differentials

Answer 8

Hypoglycaemia
Migraine aura
Focal epilepsy 
Hyperventilation 
Retinal haemorrhage

Question 9

List the investigations for TIA

Answer 9

FBC
ESR
U&Es
Lipids
CXR
ECG
Carotid doppler
Angiography CT 
Diffusion weighted MRI
Echo

Question 10

How is a TIA treated?

Answer 10

Modify cardiovascular risk factors - optimise BP, hyperlipidaemia, help stop smoking, DM

Antiplatelet drugs - 300mg aspirin OD for 2/52, then 75mg Clopidogrel OD or if not tolerated 75mg slow release dipyridamole OD

Anticoagulate if cardiac source of emboli

Carotid endarterectomy

Question 11

Who and when is carotid endarterectomy performed on?

Answer 11

Perform within 2 weeks of first presentation if 70-99% stenosis and operative risk is acceptable

Question 12

Who has a higher carotid endarterectomy operative risk?

Answer 12

Females
> 75y 
Increased SBP
Contralateral artery occluded 
Ipsilateral carotid syphon/external carotid stenosed

Question 13

What should you do with aspirin pre-operatively in a patient undergoing carotid endarterectomy

Answer 13

Aspirin should NOT be stopped pre-operatively

Question 14

Why is carotid endarterectomy surgery preferred to endovascular carotid artery angioplasty with stenting?

Answer 14

Angioplasty with stenting has higher peri-procedure stroke and mortality rates

Question 15

Who is carotid artery angioplasty done on?

Answer 15

Those who can not tolerate surgery

Question 16

What are the rules surrounding driving after a TIA?

Answer 16

Do not drive for a month

Question 17

Which scoring system is used to stratify patients at high risk of having a stroke after a suspected TIA

Answer 17

ABCD2 score

Question 18

Describe the ABCD2 score

Answer 18

Age >60yo (1 point)
BP >140-90 (1 point)
Clinical features - unilateral weakness (2 points) and speech disturbance without weakness (1 point)
Duration of symptoms - >1hr (2 points), <1hr (1 point)
Diabetes

Score >4 indicates high risk of early stroke and must be assessed by specialist within 24hrs
Score >6 strongly predicts a stroke