TIA Transient Ischaemic Attack?
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1 TIA Transient Ischaemic Attack? OR Transient loss of function (TLOF) Tal Anjum Consultant Stroke Physician, Morriston Hospital Training & education lead, WASP (Welsh Association of Stroke Physicians)
2 Qs. 1: 75, presented on Sunday with recurrent episodes (x 11) of right hand numbness and slurred speech over 2 weeks. The episodes are very similar in nature, each lasting 10 to 40 minutes with complete resolution. She is asymptomatic now. How would you manage her? 1. Admit, give Aspirin etc, refer for dopplers & urgent specialist review 2. Admit, brain imaging, Aspirin etc, urgent specialist review 3. Give Aspirin etc, discharge with urgent TIA clinic referral 4. Discharge without any antiplatelets, refer to TIA clinic 5. Admit, urgent brain imaging, review again to decide further Rx
3 Transient loss of function (TLOF) 1. Definition (and myths ) 2. Causes of a TLOF 3. Clinical presentation 4. Differential diagnoses/ mimics 5. Investigations 6. Management 7. Summary..
4 1. Definition Sudden onset of focal loss of neurological (cerebral or monocular) function, with symptoms lasting less than 24 hours and which, after adequate investigation, is presumed to be due to embolic or thrombotic vascular disease in an arterial territory WHO 1988
5 1. Definition Myths Myth - any neurological deficit lasting 24 hours or less is a TLOF Most TLOFs recover within 1 to 2 hours Symptoms hardly ever persist more than a few hours. Consider minor stroke / a mimic if they do
6 1. TLOF - Key Features Sudden onset (vs. Gradual onset in SOL/MS) Focal clinical deficits (vs. global deficits e.g. TLOC) Loss of function (vs. Positive symptoms in migraine / seizures) Symptoms related to arterial territory Identifiable (vascular) risk factors
7 1. Transient loss of function (TLOF) a practical definition Sudden onset Focal Neurological/monocular deficit due to an nontraumatic vascular event, Symptoms resolving within 1 to 2 hours
8 Picture from 2. Causes of TLOF Local clot formation (atherothrombotic) Hypertension Diabetes Dyslipedemia Smoking Other vascular risk factors Clot migration from a distant source (Embolic) Cardiac AF, Post MI / LV thrombus Endocarditis Large vessel disease Carotid /Vertebral artery Aortic arch disease
9 3. Clinical Features Carotid artery territory Unilateral weakness (face, arm, or leg) Unilateral numbness / paraesthesia Dysphasia Dysarthria Amaurosis fugax
10 3. Clinical Features Vertebro-basilar territory Hemiplegia / hemisensory disturbance Bilateral blindness or hemianopia Bilateral motor or sensory deficit Diplopia Vertigo Vomiting Dysarthria Dysphagia Ataxia
11 3. Clinical Features Physical signs None or trivial neurological signs CVS abnormalities e.g. AF, HTN Evidence of vascular disease (elsewhere)
12 3. Clinical Features What s not a TLOF Non-focal symptoms General weakness/numbness Syncope or incontinence Isolated symptoms e.g. Vertigo (labyrinthine) Slurred speech / dysphagia (neuro-muscular or structural) Double vision (ophthalmic disorders) Acute confusion Disorientation /impaired attention/ consciousness D/D: Isolated receptive dysphasia / visuo-spatial perception problem (? TIA)
13 Qs. 2: 56 brought to GP by wife. After 10k cycling (in summer) he could not remember cycling back or where things were in the house. He was repeating questions despite careful & repeated explanations by wife. Symptoms resolved within ~ 8 hours. Referred to stroke team as suspected TIA. Examination was unremarkable. What s the most likely diagnosis? 1. TIA affecting temporal lobe 2. Transient Global Amnesia 3. Transient Epileptic Amnesia 4. Brain tumor 5. Migrane
14 Migraine Focal seizures 4. Differentials / Mimics Structural brain disorders - SDH, AVM etc Malignant hypertension Hypoglycemia Severe anaemia Paroxysmal symptoms - MS, peripheral nerve lesions, labyrinthine disorders Somatisation
15 Diagnosing TLOF Depends ~ entirely on clinical history Implications of misdiagnosis Patients NHS Un-necessary Rx +/_ potential ADR s Primary condition Untreated Resource implications cost
16 5. Investigations Blood tests FBC, renal function, lipid profile ECG AF, cardiac ischaemia Carotid dopplers for anterior circulation TLOFs & Minor strokes only important to distinguish vascular territory on history
17 Yield in TLOF : 1% 5. Investigations Routine CT brain for TLOF? Use: Mainly to exclude structural lesions (SOL, SDH etc) Intracerebral haemorrhage does not cause TLOF Implications: Cost Radiation to pt
18 5. Neuro-imaging policy in TLOF Punch line People being considered for carotid endarterectomy (CEA) where it is uncertain whether the stroke is in the anterior or posterior No circulation Routine CT heads for TLOFs Unless People with TIA where haemorrhage needs to be excluded, for example long duration symptoms (MR better) or people on anticoagulants 1. Longer duration of symptoms Where alternative diagnosis (for example migraine, epilepsy or tumour) is being considered 2. Patient in AF (anticoagulation) Atypical features, persistent symptoms, headaches etc 3. Atypical symptoms NICE/RCP 2013
19 6. Medical Management Management of vascular risk factors Anti-platelet therapy Statins Anticoagulation (if in AF) Anti-hypertensives (ACEi+Thiazide diuretic) Advice regarding driving (DVLA) 1 month if 1 episode only 3 months if recurrent TIAs
20 6. Carotid Endarterectomy (CEA) Criteria for suitability for CEA Carotid TIA or stroke with good recovery 50-99% internal carotid stenosis ~ 5000 candidates in England & Wales (20 in a DGH) would prevent 500 strokes/year Morriston CEA/year
21 Risk of recurrent stroke during 90 days after TLOF (Express phase , phase ) Rothwell, Giles, Chandrateva, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. 2007; 370:
22 Local services 1 step further Specialist TIA clinic runs on Weekdays only However Referrers (GP/A&E) are asked to initiate preventive treatment (anti-platelets, statins +/- BP Rx) Risk stratify (ABCD2) rapid referral for vascular imaging & TIA clinic
23 Prompt preventive treatment of TIA could reduce the need for a weekend TIA service QT Anjum, L Dacey, M Wani Stroke, Feb 2013;44AP386.pdf Planned service evaluation ( ) Retrospective analysis of TIA service database, clinic letters any recurrent presentation (s) Assess effects of preventive treatment started by referrers Recurrent neurovascular events Complications of early treatment
24 Summary Results Referrers started preventive Rx in 89% patients 12% of these patients had minor ADR s headaches, GI upset, myalgia, rash, bruising none required hospitalisation Recurrent TLOF/Stroke in the early treatment arm (0.7%) vs. Recurrent events in the non-treated group (25%) p <0.0001
25 Qs. 3: 59 - attends A&E on a Saturday after suddenly developing dysarthria, diploplia, numbness & pronounced weakness of right face & left hand which lasted ~2 hours. Past medical history: Hypertension, hyperlipidemia, claudication Current smoker (40 pack year history) She has stopped her medications (few months ago) Exam: BP 150/85, neurological and CV examination normal ECG shows AF what will you do? 1. Start secondary vascular prevention, smoking cessation advice, TIA referral, discharge home 2. CT head, anticoagulate 3. Admit for Rx and Carotid Dopplers 4. Combined option Combined option 2 + 3
26 Summary of Transient Loss of Function Good history identifies a TLOF 10% risk of stroke in the week after TLOF Urgent evaluation & early preventive treatment reduce recurrence after a TLOF by 80% at 90 days
27 Summary of Transient Loss of Function Early anticoagulation if AF Timely OP referral to stroke team Modification of vascular risk factors Hospital admission for TLOF exceptional circumstances ; Crescendo TLOFs (2 or more events in a week) Ongoing focal neurological symptoms TLOF symptoms on anticoagulation
28 Qs. 1: 75, presented on Sunday with recurrent episodes (x 11) of right hand numbness and slurred speech over 2 weeks. The episodes are very similar in nature, each lasting 10 to 40 minutes with complete resolution. She is asymptomatic now. How would you manage her? 1. Admit, give Aspirin etc, refer for dopplers & urgent specialist review 2. Admit, brain imaging, Aspirin etc, urgent specialist review 3. Give Aspirin etc, discharge with urgent TIA clinic referral 4. Discharge without any antiplatelets, refer to TIA clinic 5. Admit, urgent brain imaging, review again to decide further Rx
29 Images anonymised, patient consent obtained
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