QuestionSBA
QuestionChoice
Migraine aura can be in the form of visual or sensory phenomena. Patients describe different experiences, which can including blurring of vision, seeing flashes or floaters or the sensation of pins and needles/ tingling in the arms +/- legs or face. These symptoms can mimic stroke; however, in migraine, they would typically be followed by other migraine symptoms such as nausea/vomiting, aversion to lights (photophobia) and characteristic unilateral headache
33476
d
Migraine aura
QuestionChoice
In stroke, the deficit would not self-resolve as described in the stem
33474
b
Stroke
QuestionChoice
GCA most commonly affects women over 50 and is not associated with poor vascular health. Symptoms of GCA classically include a characteristic headache with tenderness over the temple region and jaw claudication pain. _It can cause amaurosis fugax_ but it would not present as the sole symptom of the condition, as can be the case in the context of a TIA. Visual loss in GCA can be irreversible, which is why it is important to promptly treat the condition with corticosteroids to prevent this from occurring
33475
c
Giant cell arteritis (GCA)
QuestionChoice
Patients with angle-closure glaucoma get an acutely red and painful eye. Their vision can become blurred, and patients often report seeing haloes around lights. If the condition is not treated in time and total visual loss occurs, this is **irreversible**
33477
e
Glaucoma
QuestionChoice
Amaurosis fugax refers to painless temporary loss of vision (classically monocular, though more rarely can be binocular) and, in this instance, is reflective of a form of TIA. A TIA is defined as a sudden neurological deficit that entirely resolves within a 24-hour window and classically lasts only minutes. It often reflects carotid artery stenosis. This patient has significant vascular risk factors and a history of a previous vascular event which makes this option even more likely
33473
a
Transient Ischaemic Attack (TIA)
QuestionComment
Amaurosis fugax can be the presenting feature of GCA so have to disagree with the explanation on that answer. 
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# 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
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Neurology
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A 52-year-old man presents to the Emergency Department following a temporary loss of vision in his right eye. He was cleaning the kitchen and suddenly lost vision in his right eye. This returned within approximately 5 minutes. The left eye was not affected, and there were no other associated symptoms. He has a past medical history of hypercholesterolaemia, type 2 diabetes, hypertension, obesity and has had a previous myocardial infarction 18 months ago.

What is the most likely diagnosis?
a