A 75-year-old gentleman presents as an urgent patient at the end of a morning GP surgery. After breakfast this morning he noticed some difficulty ‘getting his words out’ and his wife said that his speech was slurred. The episode lasted for about 90 minutes and he now feels back to normal. When you examine him, he has a blood pressure of 148/96, his speech is normal and cranial nerves are intact. A thorough peripheral neurological examination reveals no deficit. He has no previous history of diabetes.
1. What is the most likely diagnosis?
This gentleman has a history that is classical for a transient ischaemic attack (TIA).
2. Which scoring system can be used to calculate his risk of a subsequent stroke?
His risk of a subsequent stroke can be calculated using the ABCD2 scoring system.
The scoring is calculated according to the following clinical features:
- A: Age > 60 = 1 point
- B: Blood pressure > 140/90 = 1 point
- C: Clinical features of the TIA
- Unilateral weakness = 2 points
- Speech disturbance without weakness = 1 point
- D1: Duration of symptoms
- > 60 minutes = 2 points
- 10-59 minutes = 1 point
- < 10 minutes + 0 points
- D2: Diabetes = 1 point
The corresponding two-day risks for a subsequent stroke are:
- 0-3 = 1%
- 4-5 = 4%
- 6-7 = 8%
3. How should this patient be managed?
He is at high risk of a subsequent stroke as he has an ABCD2 score of 5, and should therefore be given a stat dose of 300 mg aspirin and seen by a specialist within 24 hours of onset of his symptoms.
It is also important to address his risk factors and to think about secondary prevention, but this would be more appropriate once the diagnosis is confirmed and following seeing the stroke team.
For further information please view the guidance from NICE:
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