Transient Ischaemic Attack

Question 1

most common source of emboli in tia?

Answer 1

carotid atherosclerosis

Question 2

other risk factors apart from the bait cvs factors?

Answer 2

Polycythaemia rubra vera

COCP - contraceptives

Hyperlipidaemia

Alcohol

Clotting disorders

Question 3

which 2 blood territories can be affected?

Answer 3

carotid and vertebrobasilar

Question 4

What would be the consequence of the carotid territory being affected?

Answer 4

Unilateral

Most often affect the MOTOR AREA: weakness an arm, leg or one side of the face

Dysarthria

Broca’s dysphasia (if Broca’s area is involved)

Amaurosis fugax (painless fleeting loss of vision caused by retinal ischaemia)

Question 5

What would be the consequence of the vertebrobasilar territory being affected?

Answer 5

Vertebrobasilar Territory

Homonymous hemianopia (if ophthalmic cortex is involved)

May be bilateral visual impairment

May be hemiparesis, hemisensory symptoms, diplopia, vertigo, vomiting, dysarthria, dysphagia or ataxia

Ask about weakness, facial drooping, gait disturbance, confusion, memory loss, dysarthria or abnormal behaviour

Check for simultaneous cardiac symptoms (e.g. palpitations)

Question 6

Management plan?

Answer 6

Patients with acute neurological symptoms that resolve completely within 24 hrs should be given;

1. 300 mg Aspirin immediately and assessed urgently within 24 hrs - by SPECIALIST!

Patients with Confirmed TIA should then afterwards receive :

1. Clopidogrel - 300 mg loading dose and 75 mg thereafter (i think its just aspirin then lower the dose)
2. High-Intensity Statin Therapy - e.g. atorvastatin 20-80 mg

Secondary Prevention;
Antiplatelets  
Antihypertensives  
Lipid-modifying treatments  
Management of AF

Question 7

how do you assess future stroke risk in tia patients?

Answer 7

ABCD2 score ; assesses likelihood of stroke about 2 days post tia.

A: Age >= 60 years

B: Blood pressure
BP >= 140/90 mmHg

C: Clinical features
Unilateral weakness 2 points
Speech disturbance without weakness 1 point

D1: Duration of symptoms
>= 60 minutes 2 points
10-60 minutes 1 point
<10 minutes 0 point

D2: Diabetes
Diabetic 1 point

Question 8

Complications of a TIA?

Answer 8

1. Stroke + permanent disability - The risk of recurrent stroke is high in the first 7 days following a TIA. Start secondary prevention therapy immediately once the diagnosis of TIA is confirmed.
2. Myocardial infarct

Question 9

how do we ivx a TIA?

Answer 9

1. Blood glucose; rule out hypo as cause
2. ECG - rule out AF and arrhythmias (myocardial iscahemia)
3. FBC and U&E; exclude infection + electrolyte disturbance as causes of n deficit
4. Fasting lipids; hypercholesterolaemia?
5. Clotting; PT, INR, aptt -> exclude coagulopathy

Question 10

when would a CT be indicated in a TIA?

Answer 10

Request an urgent CT scan of the head in patients taking an anticoagulant or with a bleeding disorder to exclude haemorrhage

or if suspecting intracranial cause

otherwise don’t

Question 11

Sugegst diagnostic tools in TIA

Answer 11

It is important to urgently confirm or refute the diagnosis of suspected TIA with specialist opinion because there are no reliable diagnostic tools

Could use the National Institutes of Health Stroke Scale (NIHSS) to help identify the need for urgent treatment (thrombolysis). Admit anyone with suspected stroke directly to a hyperacute stroke unit.

Question 12

How would we treat a carotid stenosis?

Answer 12

If above 70% stenosed : Carotid Endarterectomy