Neurology
Question 132 of 180
A 72 year old patient presents to the Emergency Department after experiencing a funny episode lasting for about 30 minutes, where her voice was slurred and she had word-finding difficulties. She has now recovered and has none of the earlier symptoms. She has a past medical history of hypertension for which she takes amlodipine. Her observations are recorded as:
- Heart rate: 85 beats per minute
- Blood pressure: 142/90 mmHg
- Respiratory rate: 15 breaths per minute
- Oxygen saturations: 98% on air
- Temperature: 37.0°C
- Blood glucose: 8.9 mmol/L
What is the single most likely diagnosis?
Answer:
Suspect a TIA if:- The person presents with sudden onset, focal neurological deficit which has completely resolved within 24 hours of onset and cannot be explained by another condition such as hypoglycaemia. Most TIAs are thought to resolve within 1 or 2 hours but can persist for up to 24 hours. Focal neurological deficits may include:
- Unilateral weakness or sensory loss
- Dysphasia
- Ataxia, vertigo, or incoordination
- Syncope
- Sudden transient loss of vision in one eye (amaurosis fugax)
- Homonymous hemianopia
- Cranial nerve defects
Transient Ischaemic Attack
Neurology
Last Updated: 5th May 2022
Transient ischaemic attack (TIA) is defined as a transient (less than 24 hours) neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of acute infarction.
Risk factors
Risk factors for stroke and TIA include:
- Lifestyle factors associated with cardiovascular disease such as:
- Smoking
- Alcohol misuse and drug abuse (for example cocaine, methamphetamine)
- Physical inactivity
- Poor diet
- Established cardiovascular disease such as:
- Hypertension
- Permanent and paroxysmal atrial fibrillation (AF)
- Infective endocarditis
- Valvular disease
- Carotid artery disease
- Congestive heart failure
- Congenital or structural heart disease including patent foramen ovale
- Other factors such as:
- Age — the risk of having a stroke doubles every decade after the age of 55.
- Gender — Men are more likely than women to have a stroke at younger age. In women, an increased risk of stroke has been associated with current use of oral contraceptives, migraine with aura, the immediate postpartum period, and pre-eclampsia.
- Hyperlipidemia
- Diabetes mellitus
- Sickle cell disease
- Antiphospholipid syndrome and other hypercoagulable disorders
- Chronic kidney disease
- Obstructive sleep apnoea (OSA)
Clinical features
Suspect a TIA if:
- The person presents with sudden onset, focal neurological deficit which has completely resolved within 24 hours of onset and cannot be explained by another condition such as hypoglycaemia. Most TIAs are thought to resolve within 1 or 2 hours but can persist for up to 24 hours. Focal neurological deficits may include:
- Unilateral weakness or sensory loss
- Dysphasia
- Ataxia, vertigo, or incoordination
- Syncope
- Sudden transient loss of vision in one eye (amaurosis fugax)
- Homonymous hemianopia
- Cranial nerve defects
Differential diagnosis
Many conditions (sometimes known as stroke mimics) can present with similar clinical features to stroke and TIA. These include:
- Toxic/metabolic disturbance such as:
- Hypoglycaemia
- Drug and alcohol toxicity
- Conditions which can cause dizziness or disturbed balance such as:
- Syncope
- Peripheral vestibular disturbance — vertigo or dizziness
- Neurological conditions such as:
- Seizure
- Migraine with aura
- Demyelination
- Peripheral neuropathies such as Bell’s palsy
- Spinal epidural haematoma
- Trauma
- Systemic or local infection including:
- Central nervous system abscess, meningitis and encephalitis
- Encephalopathies such as hypertensive encephalopathy or Wernicke’s encephalopathy
- Space occupying lesions including:
- Tumour, subdural haematoma
- Other conditions such as:
- Acute confusional state
- Dementia
- Vasculitis
- Somatoform or conversion disorder
Initial management
If the person has had a suspected TIA within the last week:
- Give aspirin 300 mg immediately (with proton pump inhibitor cover where appropriate) unless:
- They have a bleeding disorder or are taking an anticoagulant (haemorrhage requires exclusion, arrange urgent assessment and imaging)
- They are taking low-dose aspirin regularly (continue the current dose of aspirin until reviewed by a specialist)
- Aspirin is contraindicated (discuss management urgently with the specialist team)
- Arrange urgent assessment by a specialist stroke physician
- 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
- 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
- Discuss the need for admission or observation urgently with a stroke specialist if the person:
- Has had more than one suspected TIA (sometimes known as crescendo TIA)
- Has a suspected cardioembolic source or severe carotid stenosis
- May be unable to attend for urgent review or lacks a reliable observer at home to contact emergency services if further symptoms occur
If the person has had a suspected TIA which occurred more than a week previously:
- Refer for specialist assessment as soon as possible within 7 days
- Assess for atrial fibrillation and other arrhythmias
Give all people with suspected TIA and their family/carers information on the recognition of stroke and TIA and advise them to call 999 immediately if symptoms occur. Advise the person not to drive until they have been seen by a specialist (when definitive guidance will be given).
DVLA guidance:
- A patient with a single diagnosed TIA must not drive for 1 month but need not notify DVLA.
- A patient with multiple TIA must not drive and must notify DVLA. Multiple TIAs over a short period will require no driving for 3 months. Driving may resume after 3 months if there have been no further TIAs.
Specialist investigation and management
- 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.
- Everyone with TIA who after specialist assessment is considered as a candidate for carotid endarterectomy should have urgent carotid imaging.
- Ensure that people with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of 50 to 99% according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria are assessed and referred urgently for carotid endarterectomy.
Prognosis
TIAs are associated with a high risk of stroke in the following month and up to 1 year afterwards. Estimates of risk of stroke following a TIA vary depending on the source and have been reported as:
- 3.9–5% within the first 2 days.
- 5.5–8% within 7 days.
- 7.5–12% within 30 days.
- 9.2–17% within 90 days.
A patient’s 90 day risk can be significantly lowered with rapid investigation and aggressive management.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
