Transient ischaemic attack (TIA)

Temporary (usually embolic from carotid atheroma) occlusion of cerebral circulation causing focal neurological deficit lasting <24h.

Amaurosis fugax: Temporary occlusion of retinal artery lasting <24h.

Epidemiology

High incidence: 0.4 per 1000 per year

Highly predictive of future CVA and MI (composite risk almost 10% per year)

On examination

  • Focal neurology (see ischaemic stroke)
  • Carotid bruit: High grade stenosis, bruit can be absent
  • Cardiac murmur
  • Atrial fibrillation
  • HTN
ABCD2 Score

A – Age >=60 (1)
B – BP>=140/90 (1)
C – Clinical unilateral weakness (2), speech alone (1)
D – Duration >1 hour (2), 10-59mins (1)
D – Diabetes (1)

Score =<3: 1% 48h risk of stroke
Score 4-5: 4% 48h risk of stroke – Hospital observation justified in most situations
Score >=6: 8% 48h risk of stroke, 36% 7 day risk of stroke

Differential

  • Seizure
  • Migraine
  • Syncope
  • Peripheral vestibular disease
  • Demyelination

Diagnosis

  • FBC, ESR
  • U&E, CRP, Lipids
  • Glucose
  • Non-contrast CT – signs of acute infarct?
  • ECG/Holter – rule out AF
  • Echocardiogram – rule out valvular heart disease, thrombus, PFO
  • Carotid doppler +/- angio

Treatments

  • Antiplatelet:
    • RCP 2016 (UK): Clopidogrel monotherapy
    • Meta-analysis of the various combinations that have previously been advocated (dual antiplatelets vs. aspirin, dual vs. clopidogrel, dual with ticagrelor or prasugrel vs. aspirin, aspirin vs. clopidogrel etc.) revealed that in the secondary prevention cohort there was no additional benefit to dual antiplatelet therapy when compared to clopidogrel [ref]
    • The results are driven by the findings of the MATCH trial [ref] which concluded that…
Adding aspirin to clopidogrel in high-risk patients with recent ischaemic stroke or transient ischaemic attack is associated with a non-significant difference in reducing major vascular events. However, the risk of life-threatening or major bleeding is increased by the addition of aspirin.Diener et al., 2004 (Lancet)
  • If cardioembolic, consider warfarin
  • If carotid artery stenosis >50%, ¬†consider carotid endarterectomy, depending on preoperative risk, or endovascular stenting
  • Blood pressure control
  • Driving: No driving for 1 month, inform DVLA if multiple, or prolonged deficit