QuestionSBA
QuestionChoice
Haemorrhagic stroke can present similarly; however, symptoms would not self resolve within 24 hours
33725
c
Haemorrhagic stroke
QuestionChoice
Transient ischaemic attack (TIA) is an ischaemic cerebrovascular event that self-resolves within 24 hours. Risk factors include age, pre-existing cardiovascular disease, hypertension, atrial fibrillation and smoking. This patient has a history of cardiovascular disease in the presence of symptoms suggestive of an ischaemic cerebrovascular event. As this has since resolved, this is most likely a TIA. This patient should be given 300mg of aspirin and referred to the TIA clinic (within 24 hours) to confirm the diagnosis
33723
a
Transient ischaemic attack
QuestionChoice
Hypoglycaemia should be ruled out in every patient presenting with a TIA. However, there are no risk factors for hypoglycaemia like insulin therapy, sulphonylurea therapy, liver disease, malnutrition or insulinoma. There is also no mention of this patient's symptoms resolving upon eating sugar. Therefore TIA is the more likely diagnosis
33726
d
Hypoglycaemia
QuestionChoice
Bell's palsy is an idiopathic lower motor neurone lesion of the facial nerve. It presents with ipsilateral weakness of the whole side of the face, with no sparing of the eyebrows. It does not present with arm weakness and will not resolve after one minute
33727
e
Bell's palsy
QuestionChoice
Ischaemic stroke can present similarly; however, symptoms would not self resolve within 24 hours
33724
b
Ischaemic stroke
Concept
Chapter
# Summary

A Transient Ischaemic Attack (TIA), colloquially known as a "mini-stroke", represents a sudden focal neurological deficit of vascular origin, characterised by symptom resolution typically within an hour. The absence of an acute infarct on imaging differentiates it from a stroke. Key signs and symptoms include speech difficulty, or arm/leg weakness or sensory changes. Important differential diagnoses include focal seizures, migraine, and intracranial bleeding. Investigations primarily involve neuroimaging, while management aims at reducing future stroke risk with lifestyle changes, control of vascular risk factors, and initiation of antiplatelet therapy. NICE guidelines recommend immediate referral for individuals with suspected TIA for assessment within 24 hours.

# Definition

A transient ischaemic attack (TIA) is a sudden-onset focal neurological deficit with a vascular aetiology, typically resolving symptoms within less than 1 hour. 

# Epidemiology

TIA is a significant health concern worldwide due to its association with future stroke risk. 

The incidence is 230 cases per 100000 person-years.

Risk factors include:
 
* Hypertension
* Diabetes mellitus
* High cholesterol
* Atrial fibrillation
* Carotid stenosis
* Smoking
* Family history of cardiovascular disease/stroke
* History of cardio-embolic events

# Signs and Symptoms

Patients typically present with a sudden onset of focal neurological deficits which may include:

- Speech difficulty (dysphasia)
- Arm or leg weakness
- Sensory changes 
- Ataxia, vertigo or loss of balance
- Visual disturbance: Homonymous hemianopia, diplopia 

Symptoms of TIA are transient, with most resolving within 1 hour.

# Differential Diagnosis

In assessing for a TIA, clinicians should consider the following differential diagnoses:

- **Stroke**: Persistent symptoms with evidence of ischaemia on MRI imaging
- **Focal motor seizures**: These might be suggested by positive symptoms preceding the weakness, such as shaking.
- **Migraine with aura**: Characterized by a preceding aura which may present with visual disturbances, tingling, or numbness, followed by headache.


# Investigations

To confirm the diagnosis and assess the extent of vascular disease, the following investigations are generally recommended:

- Neuroimaging 
	- The preferred modality is MRI to assess for any evidence of ischaemia, haemorrhage or consider alternative pathologies
- Carotid ultrasound (looking for carotid stenosis
- Echocardiogram (looking for cardiac thrombous)
- 24 hour tape (looking for atrial fibrillation)
- Blood tests (including glucose, lipid profile, clotting factors)


# Management

Patients who have had a suspected TIA should be referred for immediate assessment, ideally to be seen **within 24 hours** of onset of symptoms. The aim of management is to reduce the future risk of stroke and includes:

- Lifestyle modifications (smoking cessation, regular exercise, healthy diet)
- Control of vascular risk factors (hypertension, diabetes, dyslipidaemia)
- Initiation of antiplatelet therapy (e.g., aspirin, clopidogrel) unless contraindicated
- In selected cases, endarterectomy or stenting of the carotid artery might be indicated:
	- > 70% stenosis according European Carotid Surgery Trialists' Collaborative Group criteria (ECST) or
	- > 50% according to North American Symptomatic Carotid Endarterectomy Trial criteria (NASCT)

# References

[Click here for NICE Clinical Knowledge Summaries](https://cks.nice.org.uk/topics/stroke-tia/management/suspected-transient-ischaemic-attack/)
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Transient Ischaemic Attack
Topic
34
Neurology
6745
A 72-year-old man presents to the emergency department with right-sided arm and face weakness that occurred 40 minutes ago. These symptoms lasted for 1 minute and then resolved. He has a past medical history of two myocardial infarctions and peripheral vascular disease.

What is the most likely diagnosis?
a