Transient Ischaemic Attacks

INTRODUCTION

Some ischaemic syndromes

• Transient monocular blindness (amaurosis fugax)

• Transient hemisphere attacks

• The ‘locked in’ syndrome

• Vertebrobasilar (VBI), e.g.:

  • – bilateral motor loss

  • – crossed sensory and motor loss

  • – diplopia

  • – bilateral blurring or blindness

Investigations

• CT scan or MRI

• FBE

• 12 lead ECG and carotid imaging are essential investigations in first hours

• Blood glucose, creatinine and cholesterol

• Thyroid function tests

• Carotid duplex Doppler US (for carotid territory symptoms)

• ?ECG

• Transoesophageal echocardiography and Holter or bedside cardiac monitoring likely to improve diagnosis

Management (Table S9)

• Aim to minimise risk of a major stroke (Table S9).

• Determine cause and correct (if possible).

• Cease smoking and treat hypertension (if applicable).

• Give statin treatment for hypercholesterolaemia.

• Antiplatelet therapy:

  • – aspirin 100–300 mg/d within 48 hrs or

  • – dipyridamole + aspirin 200 mg/25 mg (Asasantin SR) (o) bd or

  • – clopidogrel 75 mg (o) daily ± aspirin

• Anticoagulation therapy—warfarin or direct oral anticoagulants (DOACs)

  • – for VBI (increasing frequency TIAs)

  • – for failed antiplatelet therapy

  • – atrial fibrillation (selected cases), esp. >65 yrs

• Carotid endarterectomy: although its efficacy is uncertain it does appear to have a place in the management of carotid artery stenosis and the decision depends on the expertise of the unit. There is no evidence that surgery is appropriate for the asymptomatic patient with a stenosis less than 60% or the symptomatic patient with a stenosis less than 30%, but there is a significant benefit for a stenosis greater than 70% (and possibly >60% in asymptomatic patients).

• Carotid stenting has an evolving place; best determined in stroke unit.

Rules for carotid artery stenosis:

• 70–99%—intervention

• 50–69%—‘grey area’: refer

• <50%—observe

CHA₂DS₂–VACs criteria: Those with a CHADS of 0 require this more comprehensive system used for atrial fibrillation. This doubles the score for age ≥75 years and 1 each for vascular disease ...