If suspecting a TIA, how long must symptoms have lasted for?
< 24 hrs
Note: often TIA symptoms only last several minutes but can extend to hours or almost the full 24h period
Which of the following symptom descriptions are likely to be due to a TIA:
- Neurological impairment that spreads from one part of the body to another
- Impairment moving from one modality to another e.g. visual disturbance to tingling of a limb
- Symptoms come on gradually
NONE OF THEM!
These are all indications that it is unlikely to be a TIA!
What scoring system can be used to estimate the risk of stroke after a suspected TIA? And what elements are involved?
ABCD2 score
(no longer NICE reccomended for community assessment)
Score is out of 7 (0-3 low risk, 4-5 moderate, 6-7 high)
- Age > 60 yrs (+1)
- SBP > 140 or DBP > 90 (+1)
- Clinical features of TIA:
- Other symptoms (+0)
- Speech disturbance without weakness (+1)
- Unilateral weakness (+2)
- Duration of symptoms:
- < 10 mins (+0)
- 10-59 mins (+1)
- > 60 mins (+2)
- Hx of Diabetes (+1)
How quickly do patients with a suspected TIA in GP need to be seen in hospital?
Suspected TIA = referred for 8:30AM assessment on the morning after being seen at the GP
What is a crescendo TIA?
> 2 episodes of TIA within a week - needs urgent specialist evaluation
What conditions can mimic signs of a TIA?
These conditions can often be differentiated by the history.
- Syncope - although TIA does not usually cause TLoC
- Atypical seizures - often repetitive and sterotypical + post ictal period
- Todd paresis = occasionally following a seizure a pt can develop unilateral weakness
- Migraine - often unilateral headache, photophobia, Hx of migraine, aura
- Temporal arteritis - TA tenderness, jaw claudication, visual impairment
- Retinal haemorrhage or detatchment - unilateral vision loss / spots (goes away if patient closes that eye
- Hypoglycaemia - can cause neurological disturbances (check for gliclazide or insulin)
- Labyrinthine disorders /w vertigo - can be confused for posterior circulation TIA, BPPV occurs when moving head + is recurrent and curable with Epley manoeuvre
When a referred TIA pt is seen in clinic, what 5 investigations from this list should be done?
- MRI brain
- CT brain
- Calf US
- Blood tests: FBC, U+Es, LFT, lipids
- Carotid artery doppler
- Blood glucose
- 24h blood pressure monitor
- Height, weight and BMI
- Echocardiogram
- ECG
- Blood tests
- Carotid artery doppler
- Blood glucose
- Height, weight and BMI
- ECG
Note: MRI / CT brain is only recommended if the diagnosis is uncertain i.e. features not typical of TIA (clinics which can will often MRI pts anyway e.g. Wythenshawe)
If you have a patient with AF, what tool allows you to:
- Calculate the risk of stroke
- Calculate the reduction in risk with anti-platelets and anticoagulants + risk of bleeding with these meds
SPARC tool
- You input answers to both CHADVASc + HAS-BLED
- Provides annual risk of stroke without medication and for a variety of medications
- Provides annual risk of major bleeding (e.g. ICH, bleeding requiring hospital) for each medication
After a TIA what medications might you consider giving to a patient?
- Aspirin 300mg daily for 2 weeks
- If Atrial fibrillation + stroke or TIA:
- Pt seen in anticoagulation clinic after 2 weeks - Warfarin or Xa inhibitor (e.g. apixaban)
- If HTN:
- See HTN pathway for meds
- BP target 130/80 mmHg
- If total cholesterol high or cholesterol ratio (total/HDL) is high:
- Statin e.g. Simvastatin 40mg
What type of medication is the mainstay of stroke/TIA risk factor reduction?
How does this change if the pt has AF?
Main treatments = anti-platelets e.g. aspirin or clopidogrel
If pt has AF = anticoagulation e.g. warfarin or Xa inhibitor (apixaban)
What is the initial management of a suspected TIA in a patient seen in the community?
- Aspirin 300mg immediately then DAILY for 2-weeks unless:
- Pt has a bleeding disorder or is taking an anticoagulent (if so, then immediate admission for imaging to exclude haemorrhage)
- Pt already on low-dose aspirin
- Aspirin is contraindicated
- Refer immediately for specialist assessment within 24hrs
- If pt has had > 1 TIA in short time or suspected cardioembolic source then discuss need for urgent admission
- If pt has had suspected TIA > 7 days ago then refer to specialist asap within next 7 days
Should brain imaging be done for suspected TIA?
If so, what?
NO!!
CT-brain or MRI-brain are to be done if there is clinical suspicion of an alternative diagnosis that either scan would detect
What long term management would you consider for a TIA patient?
- Clopidogrel = 1st line (same as stroke), start after 2-weeks of aspirin 300mg
- Aspirin + dipyridamole (if can’t tolerate clopidogrel)
- Carotid endarterectomy IF:
- Pt suffered stroke/TIA in the carotid territory (consider biological diversity e.g. posterior cerebral artery coming off carotid) + not severly disabled
- Only considered if stenosis > 70% (ECST criteria) or > 50% (NASCET criteria)
