Makindo Medical Notes Comprehensive Medical Encyclopedia | Education for Healthcare Professionals

Makindo Medical Notes "One small step for man, one large step for Makindo"
Download all this content in the Apps now Android App and Apple iPhone/Pad App

MEDICAL DISCLAIMER: The contents are under continuing development and improvements and despite all efforts may contain errors of omission or fact. This is not to be used for the assessment, diagnosis, or management of patients. It should not be regarded as medical advice by healthcare workers or laypeople. It is for educational purposes only. Please adhere to your local protocols. Use the BNF for drug information. If you are unwell please seek urgent healthcare advice. If you do not accept this then please do not use the website. Makindo Ltd.

Transient Ischaemic Attack (TIA)

About

Anaesthetics and Critical Care

Obstetrics Gynaecology

Oncology

Ophthalmology

Oral Medicine and Dentistry

Statistics and Research

Stroke

Surgery

Toxicology

Trauma and Orthopaedics

Twitter

Urology

Initial TIA Management Summary
Most cases are historical with the patient now stable. If ongoing symptoms/signs are present, assess as a possible stroke. TIA symptoms: sudden onset, typically resolving in less than 20 minutes. Common Carotid symptoms: Dysphasia, hemiplegia, hemianopia, hemisensory loss, monocular blindness. Common Vertebrobasilar symptoms: Dysarthria, Diplopia, Hemiplegia, Hemisensory loss, Ataxia, Horner's syndrome, Hemianopia. Atypical stroke symptoms include shaking, lightheadedness, confusion, blackout, and dizziness. For Carotid/Vertebrobasilar symptoms, give Aspirin 300 mg OD + statin, perform ABCD2 risk assessment, and refer to TIA Clinic (Same/next day). High ABCD2 score or recurring symptoms may necessitate HASU admission – discuss with the stroke team.

Initial TIA Management Summary

Most cases are historical with the patient now stable. If ongoing symptoms/signs are present, assess as a possible stroke.
TIA symptoms: sudden onset, typically resolving in less than 20 minutes.
Common Carotid symptoms: Dysphasia, hemiplegia, hemianopia, hemisensory loss, monocular blindness.
Common Vertebrobasilar symptoms: Dysarthria, Diplopia, Hemiplegia, Hemisensory loss, Ataxia, Horner's syndrome, Hemianopia.
Atypical stroke symptoms include shaking, lightheadedness, confusion, blackout, and dizziness.
For Carotid/Vertebrobasilar symptoms, give Aspirin 300 mg OD + statin, perform ABCD2 risk assessment, and refer to TIA Clinic (Same/next day).
High ABCD2 score or recurring symptoms may necessitate HASU admission – discuss with the stroke team.

Introduction

TIAs are often a precursor to a disabling or fatal stroke and should be treated as a medical emergency.
Rapid diagnosis and treatment significantly reduce the likelihood of stroke.
Accurately confirming the diagnosis of TIA is often the biggest challenge, as symptoms can mimic other conditions.

Definition

A TIA is defined as a transient neurological event, typically lasting less than 24 hours, with no imaging evidence of infarction.
Diagnosis relies heavily on history, as there is no specific imaging or blood test for TIA, apart from the lack of brain changes on imaging.

Clinical Correlation

Unilateral Focal Neurology lasting < 20 minutes.
Common vessel occlusion and expected outcomes:
Ophthalmic artery: Amaurosis fugax (monocular blindness).
L MCA: Contralateral arm > leg weakness and dysphasia.
R MCA: Contralateral arm > leg weakness.

Establishing the Diagnosis

Historical/Examination Findings
What was the patient doing immediately before, during, and after the episode? Assess posture during the event – was the patient sitting or standing? Was there any speech difficulty, weakness, or vision changes during the event? Patients should have a clear recollection of the episode. Note any history of migraine or similar episodes in the past. Check for headache – uncommon in TIA, but significant if present. Inquire about new medications, particularly in elderly patients. Assess for other systemic symptoms or signs of infection.

Historical/Examination Findings

What was the patient doing immediately before, during, and after the episode?
Assess posture during the event – was the patient sitting or standing?
Was there any speech difficulty, weakness, or vision changes during the event?
Patients should have a clear recollection of the episode.
Note any history of migraine or similar episodes in the past.
Check for headache – uncommon in TIA, but significant if present.
Inquire about new medications, particularly in elderly patients.
Assess for other systemic symptoms or signs of infection.

Symptoms Suggesting a Non-TIA Diagnosis
Positive neurology – symptoms gradually developing or spreading, such as tingling, visual changes, or headache. Involuntary movements or convulsions. Loss of consciousness or syncope. Lack of memory of the event (e.g., transient global amnesia, delirium). Acute vertigo without additional brainstem or cerebellar symptoms/signs.

If residual neurology is present, treat as a possible stroke and consider immediate transfer to the Emergency Department. If seen in a stable state, start Aspirin 300 mg OD, advise against driving, and make an urgent referral to the TIA clinic.

Differential Diagnosis

TIA Differential Diagnoses
Stroke	Brain imaging may reveal new infarction or hemorrhage.
Migraine with Aura	Headache often follows; usually in younger patients; symptoms may cross vascular territories.
Focal (partial) Seizure	Rapid spread of sensory/motor symptoms; speech may be affected with transient speech arrest.
Transient Global Amnesia	Classic memory loss episode with no motor or sensory deficit.
Multiple Sclerosis	Typically longer than 24 hours; younger demographic; possible optic neuritis.
Syncope	Loss of consciousness or pre-syncope symptoms do not fit a TIA diagnosis.

Many patients seen in TIA clinics do not have TIAs. Each case should be evaluated carefully to avoid overdiagnosis, which can have significant implications.

Risk Assessment - ABCD2 Scoring

The ABCD2 score helps quantify TIA-related stroke risk, based on Age, Blood Pressure, Clinical features, Duration, and Diabetes.

Symbol	Clinical Feature	Criterion	Points
A	Age	≥ 60 years	+1
B	Blood pressure	≥ 140/90 mmHg	+1
C	Clinical features	Unilateral weakness	+2
		Speech disturbance without weakness	+1
D1	Duration of symptoms	≥ 60 min	+2
		10-59 min	+1
		<10 min	+0
D2	Diabetes	Yes	+1

ABCD2 estimates the 2-day stroke risk, ranging from 1% for low scores to over 8% for high scores. ABCD2 is widely recommended and can guide the need for immediate TIA clinic review.

Investigations

Immediate Evaluation: Perform prompt assessment, imaging, and initiation of treatment ideally on the same day, or the next morning.
Blood Tests: Full blood count, ESR (especially with ocular symptoms), electrolytes, fasting glucose, and lipid profile.
ECG: Check for atrial fibrillation, recent myocardial infarction, or other cardiac risk factors.
Holter Monitoring: Consider 24-hour or 7-day monitoring for paroxysmal AF.
Brain Imaging: CT or MRI as soon as possible (ideally the same day), with MRI preferred within 7 days to catch DWI changes.
Vascular Imaging: Carotid ultrasound for surgical assessment, supplemented by CT or MR angiography as needed.

Role of the TIA Clinic

Role	Comments
Diagnose TIA	Differentiate TIA from various mimics (e.g., seizure, migraine, syncope).
Identify AF	Initiate anticoagulation for stroke prevention.
Identify Carotid Stenosis	Refer for endarterectomy if symptomatic.
Address Atherosclerosis	Prescribe antiplatelet therapy and statins.

Medical Management

Atherothrombotic TIA: Use daily long-term antiplatelet therapy (e.g., Clopidogrel) or Aspirin. Anticoagulation is generally not recommended.
Cardioembolic TIA: Anticoagulate in cases of atrial fibrillation or embolic risk.
Hypertension: Target BP <140/90 mmHg or <130/80 mmHg in diabetics with ACE inhibitors or ARBs.
Lipids: Aim for an LDL <100 mg/dL with daily statins.
Other Interventions: Encourage smoking cessation, manage diabetes (Fasting glucose <126 mg/dL), and promote physical activity.

Surgical Management

Carotid Endarterectomy: Recommended within 2 weeks for significant internal carotid artery stenosis in cerebral or retinal TIA cases.
Indications by Stenosis Level:
100% occlusion: No surgery.
70-99% stenosis: Recommended, particularly in high-risk cases.
50-69% stenosis: Consider at centres with a low complication rate (<6%).
<50% stenosis: Not recommended.

References

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

Edit