Transient Ischaemic Attack Nin Bajaj Consultant Neurologist QMC & DRI

Definitions presumed to be due to thromboembolic vascular disease majority of episodes last less than 30 minutes [Warlow and Davenport, 1996; Rodgers, 1998]. source most commonly the carotid arteries, the heart (particularly in people with AF), the aorta, or the vertebrobasilar arteries defined as the sudden onset of a focal cerebral or retinal deficit that recovers within 24 hours

Definitions incidence is 0.42 per 1000 population [Rodgers, 1998] GP with a list size of 2000 people will see five new people with a TIA or a stroke each year [Eccles et al, 1998]. ~15% of people who suffer their first ever stroke have had preceding TIAs [Warlow and Davenport, 1996].

Clinical Presentation –carotid territory occurs in 80% –may cause weakness or sensory symptoms affecting an arm, leg, or one side of the face; also monocular visual loss (amaurosis fugax), dysphasia, or dysarthria –vertebrobasilar territory in 20% –may cause a hemiparesis, hemisensory symptoms, homonymous hemianopia, bilateral blindness, diplopia, vertigo, vomiting, dysarthria, dysphagia, or ataxia

Clinical Presentation Global symptoms by themselves are rarely due to TIA (e.g. unsteadiness, dizziness, syncope) Examination is usually normal but may provide evidence of risk factors (e.g. hypertension, carotid bruits, or atrial fibrillation) bruits are an unreliable guide to the presence or severity of carotid stenosis; severe stenosis may cause no bruit. [Rothwell and Warlow, 1997; DTB, 1998]

Differential Diagnosis Migrainous aura Retinal or vitreous haemorrhage Giant cell arteritis Focal epileptic seizure Intracranial lesion (e.g. tumour, subdural haematoma) Multiple sclerosis Labyrinthine disorders Peripheral nerve lesions Transient global amnesia Psychological disorders (including hyperventilation) Metabolic disturbance (e.g. hypoglycaemia) [Warlow and Davenport, 1996; SIGN, 1997a]

Differentials Migraine See patient SF Usually headache/muzzy head, nausea, photphobia/phonophobia, lethargy/malaise Sometimes visual aura Acephalic variants with persistent sensory/motor aura or speech aura are the difficulties- this tends to last hours/days

Differentials Focal Epileptic seizure If motor, repetitive stereotyped movements with Jacksonian march If sensory, positive rather than negative phenomenon, lasts seconds not minutes, many episodes without resulting in stroke

Differential Intracranial lesion These tend to give persistent regional symptoms e.g. hemiplegia If transient, tends to be due to focal seizures AVM can present a theoretical problem but again should give many episodes without resulting in stroke

Differential Multiple Sclerosis See patient LC Tends to give symptoms over weeks/months Positive not negative symptoms May not be simply carotid/vb territories e.g. transverse myelitis

Differential Transient Global Amnesia Associated with migraine, rarely epilepsy Most often, psychological stress Tends to last hours, often most of the day Tend not to be confused but just forget names, dates etc Can usually find their way home!

Differential Brain Jun;113 ( Pt 3): The aetiology of transient global amnesia. A case- control study of 114 cases with prospective follow-up. Hodges JR, Warlow CP Looked at 114 TGA & 212 TIA patients with normal controls for each None of the TGA patients had CVS risk factors Actuarial analysis showed striking difference in life expectancy 7% of TGA patients go on to develop epilepsy within 1 year Migraine is associated with TGA

Case history 1 LC 48 yo lady Originally seen 10 years before C/o short lasting episodes of paraesthesiae right arm, 10 minutes each time, frequent Further few episodes of speech going funny, lasting 15 min

LC Episodes of tingling & wobbliness of legs No fam hx of migraine Clinical exam 10 years ago- mild right arm weakness MRI-wm change Trimodal evoked- normal

LC Lp-normal, no OCB Low positive anti-cardiolipin titre Started on aspirin but told had “ms” Negative for Lhermitte’s and Uthoff’s Previously episodes of visual teichopsia, photophobia, phonophobia

LC Currently, episodes of visual blurring with nausea & fatigue Paraesthesiae (R) arm, 1-2 /month Clinical exam normal MRI films Video

LC Echo- PFO with right to left shunt Percutaneous closure Oct 2004 Warfarinised for a while Now feels “fantastic”- no episodes of slow, slurred speech or head muzziness (was this ischaemic migraine?) No new wm lesions on follow-up MRI

SF 45 yo migraineur Admitted 7/12/04 with bad migraine Since age 21 Has 4/yr Usually catamenial Often left front-temporal headache with left sided facial tingling & photophobia

SF Sometimes left sided arm weakness Sometimes word finding problems This time- sudden onset left sided headache (usually headache onset slow) Slurred speech S/B GP and given amitriptyline

SF No relief GP sent to A & E CT brain reported normal Discharged 2/7 after CT, right sided weakness CT & MRI

SF Strong hx CVA 2 x Maternal aunts (30/40) and maternal grandmother (32) Mother migraineur No hx miscarriage Ex-smoker

SF O/e Horner’s LHS Right sided hemiplegia MRI- left postero-frontal infarct MRA- complete occlusion of left ICA shortly after it’s origin Thrombophilia screen negative