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?
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This gentleman has a history that is classical for a transient ischaemic attack (TIA).
2. How should this patient be managed?
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The NICE recommendations for the management of patients with suspected TIA are as follows:
- Offer aspirin (300 mg daily), unless contraindicated, to people who have had a suspected TIA, to be started immediately.
- Refer immediately people who have had a suspected TIA for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms.
- Do not use scoring systems, such as ABCD2, to assess risk of subsequent stroke or to inform urgency of referral for people who have had a suspected or confirmed TIA.
- Offer secondary prevention, in addition to aspirin, as soon as possible after the diagnosis of TIA is confirmed.
3. What are the indications for imaging in patients that present this way?
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The NICE recommendations for imaging for people who have had a suspected TIA or acute non-disabling stroke are as follows:
- Do not offer CT brain scanning to people with a suspected TIA unless there is clinical suspicion of an alternative diagnosis that CT could detect.
- After specialist assessment in the TIA clinic, consider MRI (including diffusion-weighted and blood-sensitive sequences) to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies. If MRI is done, perform it on the same day as the assessment.
- Carotid imaging – everyone with TIA who after specialist assessment is considered as a candidate for carotid endarterectomy should have urgent carotid imaging.
Further reading:
NICE Guideline: Stroke and transient ischaemic attack in over 16s: diagnosis and initial management
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