Transient ischaemic attack

Question 1

What is the definition of a transient ischaemic attack?

Answer 1

transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction. Lasts for <24 hours

typically lasts <1 hour

Question 2

What is the immediate management of suspected transient ischaemic attack?

Answer 2

give aspirin 300mg immediately, unless:

• the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
• patient already taking low-dose aspirin regularly - continue current dose until reviewed by specialist
• aspirin contraindicated: discuss management urgently with specialist team

Question 3

What are 3 reasons why you wouldn’t give aspirin immediately to treat TIA?

Answer 3

1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
2. patient already taking low-dose aspirin regularly - continue current dose until reviewed by specialist
3. aspirin contraindicated: discuss management urgently with specialist team

Question 4

If a patient is suspected to have had a TIA but is already taking low-dose aspirin regularly, what is the recommended management?

Answer 4

continue current dose of aspirin until reviewed by a specialist

Question 5

What is recommended for patients believed to have had TIA in whom aspirin is contraindicated?

Answer 5

discuss management urgently with the specialist team

Question 6

What is recommended for patients who have had more than 1 TIA (crescendo TIA) or suspected cardioembolic source or severe carotid stenosis?

Answer 6

discuss need for admission or observation urgently with a stroke specialist

Question 7

What is the recommended TIA management if the patient has had a suspected TIA in the last 7 days?

Answer 7

arrange urgent assessment (within 24 hours) by a specialist stroke physician

Question 8

If the patient has had a suspected TIA which occurred more than a week previously, what is the recommended management?

Answer 8

refer for specailist assessment as soon as possible within 7 days

Question 9

What should you advise a person who has had a TIA to do about driving?

Answer 9

advise not to drive until they have been seen by a specialist

Question 10

What is the first line antithrombotic therapy recommended for patients who’ve had a TIA?

Answer 10

clopidogrel (as for patients who’ve had a stroke)

Question 11

What is the recommended antithrombotic therapy for patients who have had TIA who can’t tolerate clopidogrel?

Answer 11

aspirin + dipyridamole

Question 12

When is carotid endarterectomy recommended for patients who’ve had TIA?

Answer 12

if have suffered stroke or TIA in carotid territory and not severely disabled

only considered if carotid stenosis >70% according to ECST criteria or >50% according to NASCET criteria

Question 13

What are 6 risk factors for TIA?

Answer 13

1. Diabetes mellitus
2. High cholesterol
3. Hypertension
4. Smoking
5. FH of cardiovascular disease/ stroke
6. AF - for cardio-embolic TIAs

Question 14

What is the usual presentation of TIA?

Answer 14

focal neurological deficit e.g. speech difficulty or arm/leg weakness / sensory changes

transient, most symptoms resolve in 1 hour

Question 15

What are 2 symptoms which must be absence from the presentation of TIA to diagnose it?

Answer 15

1. Shaking preceding the weakness - focal motor seizure
2. Headache - migraine or intracranial bleeding

Question 16

Should you offer a CT scan of the head for suspected TIA?

Answer 16

no - unless clinical suspicion of an alternative diagnosis

Question 17

In what setting are TIAs assessed?

Answer 17

specialist assessment in TIA clinic

Question 18

What imaging may be indicated for TIA after specialist assessment in the TIA clinic?

Answer 18

MRI (including diffusion-weighted and blood-sensitive sequences) to determine territory of ischaemia/detect haemorrhage/alternative pathologies