Transient Ischaemic attack (TIA)

Question 1

Define a Transient Ischaemic attack (TIA)

Answer 1

Acute loss of cerebral/ ocular function with sudden symptoms lasting less than 24 hours mainly due to an atherothromboembolism from an artery

Question 2

Is there infarction in a TIA?

Answer 2

• No Infarction!
• Temporary focal cerebral Ischaemia due to lack of oxygen

Question 3

How do TIAs present and how long do they usually last?

Answer 3

• Symptoms maximal at onset
• usually last 5-15 minutes

Question 4

What are the risk factors for TIAs?

Answer 4

Same as IHD
- Age
- smoking
- HTN
- cardiovascular disease
- AF*
- Diabetes
- VSD* (ventricular septal defect)
- obesity/ hypercholesterolaemia

Question 5

What is the main cause of TIAs?

Answer 5

• Main cause atherothromboembolism
• mainly from the carotid artery
• cardioembolism: caused by valvular disease/prosthetic valve, after an MI, AF

Question 6

Where are the 2 places a TIA can affect and what proportion of people get them?

Answer 6

• ICA: internal carotid artery (anterior circulation) 90%
• Vertebral arteries (posterior circulation) 10%
• These 2 arteries supply the brain

Question 7

What are symptoms of a TIA?

Answer 7

Focal neurology
- ACA → weak numb contralateral leg
- MCA → weak numb contralateral side of body, face drooping with forehead spared, dysphagia (temporal)
- Amaurosis fugax - occlusion/ decreased blood flow to retina through ophthalmic, retinal, ciliary artery → BAD SIGN: OFTEN SIGNALS STROKE IMPENDING
- PCA → vision loss (contralateral homonymous hemianopia w/ macular sparing (occipital cortex affected)
- Vertebral arteries → cerebellar syndrome, DANISH with Romberg test (sensory + motor ataxia), brainstem infarct, CN (cranial nerve) lesions 3-12

Question 8

What are carotid territory specific symptoms for TIA?

Answer 8

• Amaurosis fugax
• Aphasia
• Hemiparesis
• Hemisensory loss
• Hemianopic vision loss

Question 9

What are vertebrobasilar territory specific symptoms for TIA?

Answer 9

• Diplopia, vertigo, vomiting
• Choking and dysarthria
• Ataxia
• Hemisensory loss
• Hemianopic or bilateral visual loss
• Tetraparesis
• Loss of consciousness (rare)

Question 10

How do you differentiate between a stroke and TIA?

Answer 10

Can’t differentiate between stroke and TIA until after recovery
- TIA symptoms resolve within mins usually, always <24 hours with no infarct
- stroke symptoms last 24+ hrs w/ infarct

Question 11

What are investigations for a TIA?

Answer 11

• Diffusion weighted CT/MRI → first line
• Carotid imaging with doppler ultrasound
  → Then MR/CT angiography if stenosis is found
• Bloods
• ECG - AF?
• Echocardiogram

Question 12

What might be investigated in bloods for TIA?

Answer 12

→ Glucose
→ FBC - polycythaemia
→ ESR - raised in vasculitis
→ INR - if pt is on warfarin
→ U&E
→ Cholesterol

Question 13

How to diagnose a TIA?

Answer 13

Clinically made/ usually obvious if TIA/ stroke
Scoring system:
- FAST → face, arms, speech, time
- ABCD2 (not advocated by NICE anymore)

Question 14

What is the criteria for ABCD2?

Answer 14

→ Age > 60 (+1)
→ BP > 140/90 (+1)
→ Clinical symptoms: unilateral weakness (+2) / slurred speech, no weakness (+1)
→ Duration symptoms: 1 hr + (+2) / <1 hr (+1)
→ T2DM (+1)
If scores >6 = refer to neurology asap (35.5% risk within a week)

Question 15

What is the acute treatment for a TIA?

Answer 15

loading dose of Aspirin 300mg + refer to specialist to be seen within 24hrs of onset of symptoms

Question 16

What is the standard treatment long term?

Answer 16

Antiplatelet therapy
Aspirin 75mg daily with MR Dipyridamole or clopidogrel daily

Question 17

What are other treatments for TIA?

Answer 17

• patients with AF → anticoagulation e.g DOAC/warfarin
• carotid endarterectomy - if >70% carotid stenosis, reduces stroke and TIA risk by 75%
• Control CV risk factors → BP control, Smoking cessation, Statins, no driving for 1 month