1. TIA
The calm
before the storm

2. Aims TIA – what it is and what it’s not Assessment and investigations
Management
Discuss risk factors
Secondary stroke prevention

3. Stroke Definition
A transient ischemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours. In addition visual symptoms such as sudden onset of monocular visual loss should be included. (The National Institute of Clinical Excellence 2008 (NICE)
ASA – Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without evidence of acute infarction

4. Incidence 35 people out of every 100,000 each year have a TIA.
10–20% of those who have had a TIA will go on to have a stroke within a month & the greatest risk is within the first 48 hours.

5. Diagnostic challenges
Event occurred in the past, often not witnessed
-30% delay seeking medical attention for >24 hours
Reliant on patient’s history
-Pt may be unable to completely recall symptoms
-May use vague descriptions “dizziness”,“confused heaviness”
Clinical examination usually normal
Many causes of transient neurology (50% of pts referred to TIA clinic)
No diagnostic test

6. Non focal symptoms Faintness Light headedness General weakness
Confusion
Syncope
Non specific dizziness

7. Transient Focal Neurology
TIA
epilepsy
Migraine aura (+/- headache)
Transient Global Amnesia
Multiple sclerosis
Intracranial structural lesion
Metabolic disturbance
Many more

8. Transient monocular blindness (Amaurosis Fugax)
Sudden loss of vision in the whole or part of the visual field of one eye. Lasts seconds-minutes
Retinal ischeamia
Atherothromboembolism from ICA or cardiac embolism
Can be other cause of TMB eg glaucoma, Central or branch retinal vein thrombosis
Glaucoma
Retinal haemorrhage

9. Case study 1 At the gym, drove home
According to wife –”confused”, repeatedly asking “What day is it?
No limb or facial weakness
Symptoms resolved after 4 hours
Pt has no recollection of event
Is this a TIA

10. Transient Global Amnesia
Temporary, isolated disorder of memory
Impaired ability to form new memory
Asks pertinent questions repeatedly
Symptoms last < 24 hours
Unable to recall episode once recovered
Precise pathophysiology unclear

11. Transient Global Amnesia
3/100,000 cases per annum
More common in males
Precipitants – physical exertion, cold water exposure, overwhelming emotional stress, pain
Annual recurrence rate 3%
No increased risk of stroke

12. Case Study 2 – 27 year old male
Sudden onset numbness and weakness in (L) hand
Resolved within 1 hour
No past medical history
IS THIS A TIA

13. Right hemispheric TIA

14. TIA – what's the urgency? Stroke, MI, death 5% stroke within 2 days
Common
Serious recurrent vascular events
Stroke, MI, death
Most occur in first few days
5% stroke within 2 days
11% stroke within 1 week

15. ABCD2 Age > 60yrs = 1 point Blood pressure >140/90 = 1 point
Clinical features – Diabetes = 1point
Unilateral weakness = 2 points
Speech disturbance = 1point
Duration of symptoms > 60min = 2 points 59 mins = 1 point –
Diabetes = 1 point

16. Risk stratification ABCD2 Score 2 day risk 7 day risk 0-3 1.0% 1.2%
4-5
4.1%
5.9%
6-7
8.1%
11.7%
Johnston, Rothwell et al. Lancet 2007;369:

17. Risk Factors for Stroke
Non- Modifiable
Older age Male sex
Ethnicity Genetic Predisposition
Modifiable (Major)
Socioeconomic Class Obesity
Physical Inactivity Smoking
Alcohol Hypertension
Previous Stroke/TIA Atherosclerosis
Atrial Fibrillation
Structural cardiac abnormalities
Diabetes
Modifiable (Minor)
Diet
Recreational Drug Use
Sleep disordered breathing
Thrombophilia
Inflammation & Infection
Migraine
HRT
Table 1 – Risk Factors for Stroke. Markus et al, 2010

18. Risk Factors for Stroke
Non-modifiable Risk Factors
Helps identify those at greatest risk
Thereby enabling active treatment of those risk factors that can be modified in these patients

19. Non-Modifiable risk factors
Age – most powerful independent risk factor
Gender – male higher risk
Family history - increased risk if a first-degree relative has had coronary heart disease or stroke before the age of 55 years (for a male relative) or 65 years (for a female relative).
Ethic group
Older Age
- Strongest risk factor for ischaemic stroke and primary intracerebral haemorrhage
The incidence of stroke doubles with every decade after the age of fifty five
More than three-quarters of strokes occur in the people aged over sixty five
Men have a slightly greater risk of stroke (especially under the age of 75)

20. Modifiable risk factors
High blood pressure
Being over weight
Excessive alcohol
Smoking
Poor diet
High cholesterol
Lack of physical activity

21. Atrial Fibrillation AF is the most common cause of
cardio embolic stroke
Risk of stroke in people with AF is 5-6X greater than those in sinus rhythm
Paroxysmal AF has the same stroke risk as persistent AF and therefore should be treated the same

22. Secondary prevention Active management of modifiable risk factors
Carotid endarectomy
Pharmacological - concordance and compliance
Life style advice given to all (including information on driving & sex)
Blood pressure target
Cholesterol target 1

23. Stroke secondary prevention trials
Progress (BP lowering trial with ACE)
Match (aspirin + clop)
Caprie (clop v aspirin)
Sparcl (atorvastatin)
Blood Pressure Lowering Treatment Trialists’ Collaboration
Cochrane reviews

24. Medication in practice
Anti platelet / anticoagulant - Clopidogrel, Warfarin, NOAC
Statin – Atorvastatin,
Anti hypertensive treatment –ACE ,
Life long
(NICE 2008 RCP 2012)
Statins improve endothelial function
Plague stabilization
Anti inflammatory properties
Anti thrombitic properties

25. PCCS TIA Service
Follow on support to TIA Patient's diagnosed by NUH fast track service
Offered full health assessment, symptom and medication advise.
Support with lifestyle changes to reduce risk of TIA/Stroke
Access to phase 3 exercise programme
Access to cardiac team OT and councillor
Refer through SPAR