|Initial TIA Management Summary|
- Most cases are historial and patient better. If ongoing symptoms signs now assess as possible stroke.
- TIA: sudden onset then resolves usually less than 20 min
- Negative Carotid symptoms: Dysphasia, hemiplegia, hemianopia, hemisensory loss, monocular blindness
- Negative Vertebrobasilar symptoms: Dysarthria, Diplopia, Hemiplegia, Hemisensory loss, Ataxia, Horner's syndrome, Hemianopia
- Atypical for stroke: shaking, fitting, dizzy, light headed, confusion, blackout
- If Carotid/VB symptoms then Aspirin 300 mg OD + statin and ABCD2 and refer TIA Clinic (Same/next day)
- High ABCD2 or recurring Symptoms consider HASU admission discuss with stroke team.
Role of GP and Emergency Department: If there is any residual neurology then treat as stroke and 999 patient to the Emergency Department. If seen by GP or ED and all neurology has definitely resolved then start Aspirin 300 mg od advise patient not to drive and do immediate referral via fax or phone to local TIA clinic
|TIA differential Diagnosis and comments|
|Stroke||Brain scan may show new Infarct or Haemorrhage despite resolution of symptoms|
|Migraine with aura||Headache and positive symptoms useful. Often younger, female. Symptoms cross vascular territories including the midline. Progression is over minutes. Headache can be missing. Some symptoms and progression not explicable by single vessel obstruction. |
|Acephalgic Migraine with aura||More difficult to diagnose when there is no headache|
|Focal (partial) Seizure||Positive symptoms spread quickly over seconds. Sensory or motor or both. Speech can be affected with transient inability to speak 'speech arrest' which can be misdiagnosed as dysphasia. Seizure may suggest underlying structural brain lesions (tumour, abscess) and may need MRI/EEG if CT normal. |
|Transient Global Amnesia||Classical history very easy to differentiate from TIA|
|Multiple Sclerosis||Symptoms usually more than 24 hours. Young. Known MS. Optic neuritis |
|Nerve palsy||Pressure palsies can cause transient weakness. Be aware - radial, ulnar, common peroneal|
|Subdural Haematoma||Are they on warfarin. CT head diagnostic|
|Anxiety/Normal experience||Mild tingling and many transient neurological symptoms may be ascribed as within the normal experience|
|Subarachnoid haemorrhage||Headache should be expected. Focal TIA neurology should infer significant bleed/vasospasm|
|Syncope|| Often referred but syncope and/or loss of consciousness not typically due to TIA|
|Sepsis/Delirium e.g UTI in older person||Can cause slurred speech, confusion, ataxia and may be labelled primary neurological|
|Metabolic upset||Hypoglycaemia, Hyponatraemia, Hypocalcaemia (tingling), Hyperglycaemia. All Can cause slurred speech, confusion, ataxia and may be labelled primary neurological|
|Temporal arteritis||Must be considered in all with transient ocular symptoms - headache ? Raised ESR ? |
Much of the time the patients seen in the TIA clinic do not have TIAs. Many have had symptoms greater than 24 hours and made recovery and really have the diagnostic label of stroke. Others have syncope etc. Much depends on whether you screen referrals, the information given to the referrer on the form. We make our form as simple as possible and include an ABCD2 score but if the history on the form is clearly not TIA we decline the referral. If we have any doubt we see the patient.
ABCD2 estimates the risk of recurrence at two days from 1% for patients with low risk to 8.1% for those patients with "high risk". ABCD2 scoring is recommended in UK national guidelines and many centres offer a same-day assessment of patients at the highest risk of stroke. ABCD2 may also be useful in diagnosis. Single centre registry data (3646 patients) showed that few referrals with an ABCD2 score of 0 were subsequently found to have a cerebrovascular diagnosis. Among patients diagnosed by emergency department physicians with TIA, a higher ABCD2 score was associated with a greater likelihood that the diagnosis was confirmed on expert review .
Traditionally those with an ABCD2 score of 4 or more were considered high risk and current metrics insist should be seen=, assessed and imaged within 24 hours of initial presentation. The remainder should have the same within 7 days. The new guidance from Royal College Physicians suggests that all should be seen within 24 hours with no differentiation. It may be appropriate to perform some form of telephone triage to help separate TIA from all the other non-TIA referrals.