Transient Ischaemic Attack

Question 1

Define Transient Ischaemic Attack

Answer 1

Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction that completely resolves within 24 hours

Question 2

Aetiology of Transient Ischaemic Attack

Answer 2

Most common is carotid disease

Cardioembolic event (stasis from AF or HF)
In situ thrombosis (intracranial artery or embolism due to stenosis)
Small vessel occlusion (microatheroma, fibrinoid necrosis, lipohyalinosis)
Occlusion (hyper-coagulability, disseciton, vasculitis, vasospasm, sickle cell)

Question 3

Risk factors for Transient Ischaemic Attack

Answer 3

Cardiac: AF, valvular disease, carotid stenosis, congestive HF 
Hypertension
Diabetes Mellitus 
Smoking 
Alcohol-use disorder
Advanced age

Question 4

Symptoms of Transient Ischaemic Attack

Answer 4

Sudden onset + brief duration:
Unilateral weakness or paralysis
Dysphasia
Ataxia, vertigo, loss of balance
Sudden transient loss of vision in one eye (amaurosis fugax)
Loss of vision on one side (Homonymous hemianopia)
Diploplia

Question 5

Signs of Transient Ischaemic Attack on examination

Answer 5

Often won’t see any as signs resolve by the time of examination

Raised BP on presentation
Carotid bruit (carotid artery stenosis)

Question 6

Investigations for Transient Ischaemic Attack

Answer 6

Same as stroke

CT head: rule out stroke

ECG: visualise arrhythmias e.g. AF

Glucose: exclude hypoglycaemia 
FBC: rule out hypercoagulable states
Clotting: exclude coagulopathy 
Fasting lipid profile: risk factor, part of treatment
U+Es: exclude electrolyte distubrance
LFTs: end-organ damage 
ESR: ?vasculitis 

Echo: cardiac function + identify thrombus
Doppler + CT/MRI angiography neck: ?carotid artery stenosis

Question 7

Management for an acute Transient Ischaemic Attack

Answer 7

Suspected (on presentation)

1. Aspirin 300mg PO
2. PPI for dyspepsia
3. Refer to TIA clinic/stroke specialist + advise not to drive until then

Carotid Artery stenosis (symptomatic + significant): carotid endarterectomy

AF: CHA2DS2 - VASc and ABCD2

Question 8

Chronic management for Transient Ischaemic Attack

Answer 8

1. Clopidogrel 75mg (aspirin if allergic)
2. High intensity statin
3. AF -> LMWH, DOAC

Control Diabetes and hypertension
Smoking cessation

Question 9

Complications of Transient Ischaemic Attack

Answer 9

Stroke

MI

Question 10

Prognosis of Transient Ischaemic Attacks

Answer 10

No residual symptoms from the primary event
Most significant risk = second event causes permanent diability
8% have a stroke during hospitalisation
5% will be dead 6 months after the event