Transient Ischaemic Attacks

Question 1

Define Transient Ischaemic Attack (TIA)?

Answer 1

Rapidly developing focal disturbance of brain function of presumed vascular origin that resolves completely when 24 hrs

Question 2

What is the aetiology of TIAs?

Answer 2

It is usually embolic but may be thrombotic

Question 3

What is the most common source of emboli?

Answer 3

Carotid atherosclerosis

Question 4

How can emboli arise from the heart?

Answer 4

Atrial fibrillation
Mitral valve disease
Atrial myxoma

Question 5

When can clots from the right side of the circulation cause a stroke?

Answer 5

If there is a septal defect (e.g.PFO)

Question 6

What are the risk factors for TIAs?

Answer 6

Hypertension
Smoking 
Diabetes Mellitus 
Heart Disease (valvular, ischaemic, atrial fibrillation)
Peripheral arterial disease 
Polycythaemia rubra vera 
COCP
Hyperlipidaemia 
Alcohol
Clotting disorders

Question 7

What is the epidemiology of TIAs?

Answer 7

More common with increasing age
More common in men
15% of stroke patients would have experienced a previous TIA

Question 8

What is significant about the symptoms of TIAs?

Answer 8

Any patient presenting with acute neurological symptoms that resolve completely within 24 hrs (i.e. a suspected TIA) should be given 300 mg aspirin immediately and assessed urgently within 24 hrs

Question 9

What do we see on a history of TIA?

Answer 9

TIAs usually last 10-15 mins (but can be anything from a few minutes to 24 hrs)

Question 10

What do the clinical features of TIAs depend on?

Answer 10

The part of the brain affected

Question 11

What are the presenting symptoms of TIAs that affected the Carotid territory?

Answer 11

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

Question 12

What is Amaurosis fugax?

Answer 12

Painless fleeting loss of vision caused by retinal ischaemia

Question 13

What are the clinical features of TIAs that affect the Vertebrobasilar Territory?

Answer 13

Homonymous hemianopia (if ophthalmic cortex is involved)
May be bilateral visual impairment
May be hemiparesis, hemisensory symptoms, diplopia, vertigo, vomiting, dysarthria, dysphagia or ataxia
Check for simulataneous cardiac symptoms *e.g. palpitations

Question 14

What do we ask for in a history of TIAs that affect the Vertebrobasilar Territory?

Answer 14

Weakness 
Facial drooping 
Gait disturbance 
Confusion
Memory loss 
Dysarthria 
Abnormal behaviour

Question 15

What are the signs of TIAs on physical examination?

Answer 15

Neurologial examination may be normal because the TIA may have resolved by the time you do it
Check pulse for irregular rhythm (AF)
Auscultate the carotids to check for bruits (carotid atherosclerosis)

Question 16

What are the Primary Care Investigations that we do for TIAs?

Answer 16

Urinalysis (check for glycosuria)
FBC 
U&Es 
Lipids 
LFTs 
TSH 
ECG (may show AF or previous MI)

Question 17

What do we do for the secondary care of TIAs?

Answer 17

Unenhanced CT - if there is a possibility of a haemorrhage (e.g. if the patient is anticoagulated or has a bleeding disorder)

Question 18

How do we investigate the source of emboli for TIAs?

Answer 18

ECG (24 hr tape or cardiac monitoring may be considerd if paroxysmal atrial fibrillation is suspected)
Doppler US of carotid and vertebral arteries

Question 19

What is the management plan for TIAs?

Answer 19

Clopidogrel - 300 mg loading dose and 75 mg thereafter

High-Intensity Statin Therapy - e.g. atrovastatin 20-80 mg

Question 20

What is the secondary prevention of TIAs?

Answer 20

Antiplatelets
Antihypertensives
Lipid-modifying treatments
Management of AF

Question 21

How do we assess the future stroke risk in TIA patients?

Answer 21

ABCD2 score

Question 22

What are the possible complications of TIAs?

Answer 22

Recurrence

Stroke

Question 23

What is the prognosis for patients with TIAs?

Answer 23

VERY HIGH RISK of STROKE in the first month after the TIA and up to 1 year afterwards