Transient Ischemic Attack

A 72-year-old woman with a past history of treated hypertension presents for review. Yesterday she had a 2 hour episode where she couldn't find the right word when speaking. This has never happened before and there were no associated features. Neurological examination is unremarkable and blood pressure was 150/100 mmHg. Her only current medication is amlodipine.

What is the most appropriate management?
A. Aspirin 300 mg immediately + specialist review within 2 weeks
B. Specialist review within 2 weeks
C. Aspirin 300 mg immediately + specialist review within 24 hours
D. Aspirin 75 mg + outpatient CT brain
E. Specialist review within 24 hours

Answer:
C. Aspirin 300 mg immediately + specialist review within 24 hours

Discussion: This patient has had a transient ischaemic attack (TIA). Her age, blood pressure and duration of symptoms put her in a higher risk category. Current guidelines advocate specialist review within 24 hours. If a patient's symptoms have not fully resolved then aspirin should be withheld until an hemorrhagic stroke has been excluded. As this is a transient ischaemic attack (symptoms last less than 24 hours) aspirin should be given as soon as possible.

Transient ischemic attack 
NICE issued updated guidelines relating to stroke and transient ischaemic attack (TIA) in 2008. They advocated the use of the ABCD2 prognostic score for risk stratifying patients who've had a suspected TIA:

• A = Age >= 60 years = 1
• B = Blood pressure >= 140/90 mmHg = 1
• C = Clinical features - Unilateral weakness = 2
•                                      Speech disturbance = 1
• D = Duration of symptoms - > 60 minutes = 2
•                                            10-59 minutes = 1
• Patient has diabetes = 1

This gives a total score ranging from 0 to 7.

People who have had a suspected TIA who are at a higher risk of stroke (that is, with an ABCD2 score of 4 or above) should have: 
 aspirin (300 mg daily) started immediately
 specialist assessment and investigation within 24 hours of onset of symptoms
 measures for secondary prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors

If the ABCD2 risk score is 3 or below: 
 specialist assessment within 1 week of symptom onset, including decision on brain imaging
 if vascular territory or pathology is uncertain, refer for brain imaging

People with crescendo TIAs (two or more episodes in a week) should be treated as being at high risk of stroke, even though they may have an ABCD2 score of 3 or below.

Antithrombotic therapy 
 clopidogrel is recommended first-line (as for patients who've had a stroke)
 aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel