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Tia Tia Presentation Transcript

  • Tia slides These slides require professional interpretation and are not for personal diagnosis or treatment. Consult your doctor if you need a medical opinion.
  • TIAs - size of the problem
    • Incidence of new cases 42/100,000/yr
    • of which carotid TIAs is 34/100,000
    • Incidence of first ever stroke 200/100,000/yr
    • The incidence of new strokes 240/100,000/yr
    TIAs
  • Slides on TIAs Use and amend these slides for your lecture needs. These slides are for Physicians and require medical interpretation. They are not to be used for personal diagnosis, treatment or treatment recommendations. Consult your doctor for any medical opinion. Email your comments or new slides for inclusion to stroke@compura.com
  • CBF ml/100g/min Normal Oligaemic Electrocortical function affected Electrical failure Ionic pump failure Cell death 35 20 15 10 60 Thresholds of cerebral ischaemia
  • TIAs
    • Catchment pop. of 250,000 there will be
    • 100 new TIAs per year
    • up to another 170 'unknown to GP'
    TIAs
  • TIAs - key questions
    • Is history consistent with TIA ?
    • Is TIA carotid or vertebrobasilar ?
    • Is TIA haemodynamic or embolic ?
    • What are p/ts risk factors for TIA ?
    • What are appropriate investigations & Rx ?
    TIAs
  • TIAs
    • Risk of stroke
    • Aetiology
    • Diagnosis
    • Assessment and investigations
    • Risk factors
    • Treatment
    TIAs
  • TIA
    • 50% of TIAs go unreported
    • 6-12% develop a stroke in the first year
    • then risk CVA about 5% annually
    • risk stroke highest first few weeks
    • only 15% CVAs have h/o TIA
    TIAs
  • TIA
    • Risk death 6.3 - 8% per yr - RR x1.4
    • 25% of deaths stroke, 45% cardiac
    • Only 5-10% of TIA’s suitable for arterectomy
    • Aspirin may lead to 4% reduction strokes/yr - reduce incidence of CVA from 7% to 5% in patients with TIA (25%).
    TIAs
  • Annual risk CVA, MI, vascular death following TIA minor CVA
    • CVA 6.7 %
    • MI 2.5
    • Death 7.2
    • CVA, MI, Vascular death 8.6
    • CVA, MI, Death 10.3
    TIAs
  • TIAs
    • Risk of stroke
    • Aetiology
    • Diagnosis
    • Assessment and investigations
    • Risk factors
    • Treatment
    TIAs
  • TIAs - site
    • 10% vertebrobasilar
    • 80% carotid
    • 10% uncertain
    • 17% are purely retinal (amaurosis fugax) better prognosis
    TIAs
  • TIAs Approximate frequencies of main causes of ischaemic stroke & presumably TIAs Rarities 5% Atherothromboembolism 50% Embolism - heart 20% Intracranial small vessel disease 25% TIAs
  • TIAs - territory Carotid Either Vertebrobasilar Dysphasia +++ Monocular visual loss (am fugax) +++ Dyspraxia, visuospatial problems +++ Unilateral weakness ++ - + Unilateral sensory ++ - + Dysarthria* + - +++ Dysphagia* + - +++ Ataxia* +++ Diplopia* +++ Vertigo* + Bilateral visual loss +++ Bilateral sensory +++ Crossed sensory/motor +++ * = in isolation, not TIA + may occur - +++ v common TIAs
  • Transient ischaemic attacks TIAs
  • Carotid TIAs
    • Hemiparesis / hemisensory loss
    • Dysphasia
    • Apraxia
    • Visuospatial problems
    • Homonymous hemianopia
    • Amaurosis fugax
    TIAs
  • Amaurosis fugax
    • Risk of CVA half that of a TIA with a cerebral event
    TIAs
  • Transient ischaemic attacks TIAs
  • Vertebrobasilar TIAs
    • Vertigo, Vomiting, Ataxia
    • Diplopia - disorder of conjugate eye movement - vertical or horizontal
    • Cortical blindness or isolated hemianopia
    • Bilateral motor or sensory defect
    • Ipsilateral cranial nerve deficit and contralateral motor or sensory defect
    TIAs
  • TIAs
    • Risk of stroke
    • Aetiology
    • Diagnosis
    • Assessment and investigations
    • Risk factors
    • Treatment
    TIAs
  • TIA - diagnosis
    • The main 'diagnostic' tool for TIA is a careful clinical history Of referrals from GPs 38% in one study had a 'true' TIA,
    • 10% migraine, 9% faints, 9% 'funny turns'
    • 9% possible TIAs, 6% epilepsy, 6% vertigo
    • 0.8% hypoglycaemia, 0.4% brain tumours
    TIAs
  • TIA - diagnostic criteria (i)
    • Focal neurological or monocular symptoms
    • -ve symptom (weak-numb-dysphasia-visual loss)
    • rare +ve (paraesthesia, limb shaking, flashes light)
    • abrupt onset secs, no march or intensification
    • resolve gradually but completely, 1 hr, lasting for seconds rare - ? Afib
    TIA
  • TIA - diagnostic criteria (ii)
    • usually no warning - ?Ep, migraine or provocation
    • headache may occur during or after
    • loss consciousness rare - ?Ep, syncope
    • frequent stereotyped attacks suggest partial Ep
    TIA
  • TIA - symptoms (i)
    • Unilateral weakness/heaviness/clumsiness 50%
    • Unilateral sensory symptoms 35
    • Slurred speech 23
    • Transient monocular blindness 18
    • Difficulty speaking (dysphasia) 18
    • Unsteadiness (ataxia) 12
    TIA
  • TIA - symptoms (ii)
    • Dizziness (vertigo) 5%
    • Homonymous hemianopia 5
    • Double vision 5
    • Bilateral limb weakness 4
    • Dysphagia 1
    • Crossed motor and sensory loss 1
    TIA
  • TIAs
    • Risk of stroke
    • Aetiology
    • Diagnosis
    • Assessment and investigations
    • Risk factors
    • Treatment
    TIAs
  • Carotid bruit
    • Can’t be used to determine if symptomatic patients have ICA stenosis amenable to surgery.
    TIAs
  • Carotid bruit
    • 4% all > 45 years
    • 26 - 53% symptomatic pts
    • 10% bruit, no stenosis
    • 71% severe stenosis, no bruit
    • 30% ICA occlusion - bruit - ? ECA
    TIAs
  • Carotid bruit + TIA
    • 40% carotid TIA localised stenosis
    • Increases if TIA’s brief bruit amaurosis fugax too
    • 10% may have complete occlusion
    • Risk CVA up to 10 % yr 1, death IHD 10%/yr
    TIAs
  • Carotid bruit
    • Stroke rate, asymptomatic - 0.6% /yr asymptomatic, bruit - 2.7% /yr symptomatic ICA - 10 % /yr
    • Bruit : 0.6 - 2.4% develop TIA
    • Stroke side does not always equate with bruit side
    TIAs
  • Carotid bruit
    • Increased risk of stroke, myocardial infarction and death.
    • Bruits are absent in > 1/3 patients with high grade stenosis.
    • 10% of patients with less than 50% stenosis will have a bruit.
    • Bruit does not select out those who need endarterectomy.
    TIAs
  • TIAs - routine investigations
    • FBP
    • ESR/CRP, +/- plasma viscosity
    • U&E, blood sugar
    • Serum cholesterol - TFTs
    • ECG
    TIAs
  • TIA - who to duplex scan (i) ?
    • Symptomatic in carotid territory (TIA or non-disabling CVA)
    • Willing to take the immediate risk of operation/arteriography (perioperative stroke or death in up to 10%) for the long-term gain (unoperated risk of stroke by 2 years of up to 20%, overall gain of 10%)
    TIAs
  • TIA - who to duplex scan (ii) ?
    • Recent symptoms (past 6 months)
    • No other life threatening disease
    • No marked pulmonary/airways disease
    • No uncontrolled hypertension, cardiac failure or ischaemic heart disease
    • No clinically significant dementia
    TIAs
  • TIA - who to duplex scan (iii) ?
    • No marked frailty
    • No marked generalised arteriopathy
    • No significant chronic liver or renal disease
    TIAs
  • EEG, CT and MRI in TIA
    • Not indicated monocular
    • CT if > 1 TIA esp. carotid, arterectomy
    • Consider MRI if vertebrobasilar continuing & CT no help
    • EEG if in doubt - 35% c Ep always abnormal 50% occasionally 15% never
    TIAs
  • TIAs
    • Risk of stroke
    • Aetiology
    • Diagnosis
    • Assessment and investigations
    • Risk factors
    • Treatment
    TIAs
  • Stroke - risk factors
    • Age *
    • Male
    • BP* - causal
    • Smoking x 1.5 esp SAH
    • Fibrinogen
    • Diabetes x 2 *
    • Black / SE Asian
    • Social deprivation
    • MI / angina +
    • Cardiac failure +
    • LVH
    • A Fib - x 6, x 18 M Sten
    • Claudication +
    • Carotid bruit
    • TIA x 5 - x 10
    TIAs
  • Stroke - prevalence of vascular risk factors - first time ever cerebral infarct
    • BP > 160/90 52 %
    • Angina or MI 38
    • Current smoker 27
    • Claudication/ no foot pulses 25
    • Major cardiac embolic source 20
    • TIA 14
    • Cx arterial bruit 14
    • Diabetes mellitus 10
    Any of = 80% TIAs
  • Risk CVA, MI, vascular death following TIA minor CVA
    • PVD 2.31
    • Carotid & vertebral TIAs 2.03
    • Male 1.98
    • Residual neurological signs 1.93
    • Age 1.82
    • TIA brain vs eye 1.75
    • LVH 1.72
    • Number of TIAs past year 1.16
    TIAs
  • TIA - risk of further CVA
    • A CVA rather than a TIA
    • Frequent TIAs
    • Ulcerated plaque - soft plaque
    • Stenosis above 80% are all associated with a greater stroke risk
    TIAs
  • TIAs
    • Risk of stroke
    • Aetiology
    • Diagnosis
    • Assessment and investigations
    • Risk factors
    • Treatment
    TIAs
  • TIA - hospital admission
    • Symptoms suggestive CVA > 1hr.
    • > 2 TIAs in 1 week
    • Pyrexia + TIA
    • Severe hypertension + TIA
    • Atrial fibrillation, recent MI + TIA
    TIAs
  • TIAs
    • Treating 1,000 patients with a history of cerebrovascular disease (mild stroke/TIA) will prevent 37 cardiovascular events at 3 years (death, non-fatal stroke or myocardial infarction).
    TIAs
  • Risk reduction, non-fatal CVA/MI, vascular & non-vascular deaths, for antiplatelet Rx in TIA mild CVA 7.5% 0% 30% 16/12 15/1000 30% 15/12 14/1000 18% 15/12 13/1000 7% % reduction 15/12 months Rx 1/1000 events prevented % patients affected TIAs
  • Aspirin - TIA & Stroke
    • For 3 years 25% decrease risk of Non fatal stroke Non fatal M Infarct Death from cardiovascular cause (1,000 prevents 37 cardiovascular events in 3 years)
    TIAs
  • Drugs & ischaemic stroke
    • Aspirin in healthy middle age USA First MI relative risk down 44% GB no decrease in MI,vascular death NEJM 1997, if CRP raised does decrease MI/CVA
    • Clopidrogel - Caprie study, edge over aspirin (0.05% difference, 1:200)
    • Aspirin + persantin - ESPS2 study combination x2 effect of single.
    TIAs
  • Aspirin
    • Apparently healthy men
      • C-reactive protein > 2.1 mg/l :-
        • risk stroke double
        • risk MI tripled
          • aspirin decreased this xs risk by 53%
    NEJM 1997; 336: 973-9.
  • Dipyridamole retard Risk reduction for TIA In TIA/mild stroke - aspirin 50 mg, dipyridamol retard 200 mg bd, n = 6602 13.2% had TIA 2 yr. 12.6% had TIA 2 yr. 10.5% had TIA 2 yr. 16.4% placebo had TIA 2 yr. European stroke prevention study. J Neur Sci 1996; 143: 1-13.
  • CAPRIE - Clopidrogel
    • Inhibits ADP-platelet aggregration
    • Recent stroke , M Infarct, PVD n = 19,185: 1-3 yr, x = 1.91 yr.
      • Clopidrogel 75mg vs aspirin 325 mg
      •  MI, Ischaemic stroke, vascular death Clopidrogel 5.32% vs. Aspirin 5.83% annually p= 0.043, relative risk reduction of 8.7% intention to treat (9.4% on treatment)
    Lancet 1997; 348: 1329-39
  • Aspirin secondary prevention
    • In patients with a history of unstable angina, myocardial infarction, TIA or stroke aspirin reduces the deaths from cardiovascular causes by one sixth, non-fatal MI or stroke by 1/3 (in patients who had an annual risk of 8-11% /yr).
    • Aspirin reduces recurrent stroke by around 25%.
    TIAs
  • European stroke prevention study 2
    • Mild stroke or TIA, 2 yr follow up
    • Stroke risk (or death) 18% (13%) c aspirin
    • 16% (15%) c persantin retard
    • 37% (24%) with both
    TIAs
  • CAPRIE study
    • Recent ischaemic stroke, MI or symptomatic peripheral arterial disease
    • Follow-up 1-3 years
    • Risk ischaemic CVA, MI, vascular death Clopidrogel 5.3% per yr. Aspirin 5.8% per yr.
    • Drop out 21%, age 62.5 yr
    • (Antiplatelets Trialist’s Collab. Asp decr 25%)
    TIAs
  • Drugs & ischaemic stroke/TIA - arterial
    • Recommendations
        • TIA/CVA non cardioembolic - aspirin is the standard
        • Consider aspirin + Persantin retard
        • Conside Clopidrogel if reactions to above drugs
        • ? Clopidrogel niche in peripheral vascular disease
        • Significant carotid stenosis - arterectomy if suitable
        • Embolic stroke/TIA - consider warfarin
    TIAs
  • Carotid stenosis
    • 70 - 99% 10%/yr - CVA
    • Willing for surgery
    • Carotid TIA last few weeks/month
    • No significant intracranial arterial disease
    • Fit for surgery - BP, MI, IHD, LVF/CHF
    TIAs
  • Carotid endarterectomy
    • Symptomatic carotid artery disease TIA - retinal or cerebral 70 - 99 % stenosis, surgery better 9% c.f. 26% risk stroke in 2 years - stenosis measured angiographically - colour coded doppler & B mode ultrasonography - still imprecise correlation
    TIAs
  • Endarterectomy - TIAs
    • Aspirin decrease incidence CVA 25% 7 to 5%
    • Endarterectomy abolishes ipsilateral stroke
    • 11-12% TIA’s consideration for arterectomy
    • Arterectomy decrease incidence stroke by 1%
    • Indicated symptomatic stenosis 70-99%
    • Mortality arterectomy < 3%
    TIAs
  • Endarterectomy - guidelines
    • Asymptomatic bruit & > 60% stenosis in men, or in men & women if severe contralateral stenosis.
    • Endarterectomy halves the risk of stroke in those with severe asymptomatic stenosis, absolute risk of stroke low & surgery is usually not indicated.
    • Severe symptomatic stenosis (greater than 70%) in men and women. Risk of stroke is highest within weeks or months of the ischaemic event.
    TIAs
  • Symptomatic carotid stenosis
    • NASCET trial risk ipsilateral CVA at 2 years :- 26% for medical Rx 9% for surgical Rx
    • At 5 years risk of ipsilateral CVA 10% risk of any stroke 18% risk of death 27% In those Rx surgically.
    • Endarterectomy decreases risk CVA by x6 - x10
    TIAs
  • Symptomatic carotid stenosis
    • 10 arterectomies will save 1 stroke
    • Incidence of stroke reduction < 1%
    • Still cost efficient
    TIAs
  • Asymptomatic carotid stenosis (ACS)
    • Of 50% present in 25% hypertensives
    • Of 50% present in 12% p. vasc disease
    • Smoker c  lipids, IHD, AAA, ACS likely
    • TIA, CVA more likely c soft plaque
    • >50% stenosis 7% risk CVA 2 years
    • >50% stenosis & BP 1/3 CVA 5 years
    • Soft plaque < 75%, 20% CVA TIA 3 years
    TIAs
  • Asymptomatic carotid stenosis
    • 30% > 50 yr have some carotid artery disease
    • Stenosis > 50% in 4% middle aged & elderly
    • < 1% middle aged & elderly stenosis > 80%
    • Asymptomatic stenosis > 75% Risk ipsilateral CVA 2.5% per year (1% < 75%) Risk fatal coronary heart disease 6.5% per year
    • 5 yr medical Rx risk CVA 10.6%
    • 5 year surgical risk CVA 5.8%
    TIAs
  • TIAs - practical points (1)
    • Acute focal neurological defect monocular, clears 24 hr, usually half hr.
    • 30% c TIA get CVA by 5 years
    • Global symptoms in isolation rarely due to TIA loss consciousness, presyncope, dizziness, confusion, incontinence
    • Presence/absence carotid bruit ‘unhelpful’ for diagnosing significant carotid disease
    TIAs
  • TIAs - practical points (2)
    • Investigation include FBP, ESR, BS, lipids, ECG
    • Admit crescendo TIAs - occurring daily or >
    • Treat risk factors - AF, BP, smoking, C2H5, lipids
    • Antiplatelet therapy - 25%  CVA / MI/ vasc 
    • Warfarin for AF
    • Endarterectomy for selected pts.
    TIAs
  • TIAs - dy/dx - transient deficit
    • Migraine
    • Epilepsy
    • Intracranial tumour (up to 1 ‘TIAs’)
    • Syncope
    • Subdural
    • Hypoglycaemia
    • Demyelination
    • IC bleed - but usually lasts days
    TIAs
  • dy/dx TIA
    • Was the event vascular - very likely if
    • Signs SABE
    • Carotid territory + focal loud long ipsilateral bruit
    • M Infarct last 3-4 weeks
    • Rheumatic atrial fibrillation
    TIA
  • dy/dx TIA
    • Was the event vascular - likely if
    • A fib & NR valvular heart disease
    • Arterial bruit anywhere
    • Prosthetic heart valve & on warfarin
    TIA
  • dy/dx TIA
    • Was the event vascular - unlikely
    • < 40, years
    • no vascular risk factors
    • no symptomatic vascular disease
    TIA
  • dy/dx TIAs
    • attack usually lasts < 60 min, therefore
    • diagnosis relies on clinical history
    • BUT history/memory of event may be poor
    • diagnosis open to inter/intra-observer variation
    • so let’s concentrate on serious but remediable differential diagnoses
    TIA
    • Breakdown of transient neurological symptoms Oxford Community Stroke Project
    • 39% TIAs
    • 10.4% migraine
    • 9.6% syncope
    • 9.0% funny turn
    • 6.6% isolated vertigo
    dy/dx TIA
    • 5.8% epilepsy
    • 3.4% TG amnesia
    • < 1% isolated diplopia
    • < 1% drop attack
    • 12% possible TIA
    TIA
  • dy/dx TIA
    • Possible causes transient neurological symptoms
    • Focal ischaemia* + SA Labyrinthine disease*
    • Migraine aura* Metabolic, Gluc + , Ca, Na
    • Partial (focal) epilepsy* Peripheral nerve
    • TGA* + - Myasthenia
    • Intracranial lesion Psychological
    • MS Key : *commonest + most impt
    TIA
  • Migraine vs TIA (i)
    • Younger pt +/- family history
    • Positive focal cerebral/visual aura
    • Aura develops over 5-20 min, lasts < 60 min
    • Homonymous, unilateral or central visual c/o Zig zag, Fortification spectra, Scintillations
    TIA
  • Migraine vs TIA (ii)
    • Somatosensory or motor paraesthesia/heaviness Evolve and spread over a period of minutes e.g.. arm., face, tongue
    • Headache, nausea, photo, phonophobia cin 1 hr
    • Headache usually lasts 4 - 72 hr
    TIA
  • Migraine with aura
    • 2 attacks fulfilling B & C
    • B) At least 3 of :- i) One or more focal cerebral cortical/brainstem aura, completely reversible ii) At least 1 aura symptom develops gradually over > 4 min, or 2 or more in succession iii) No aura symptom > 1 hr iv) Headache follows aura within 1 hr
    • C) No evidence of related organic disease
    TIAs
  • Danger signs for ‘migraine’
    • sudden onset of ‘worst ever headache’
    • progressive course
    • onset with exertion
    • onset of headache during or after middle age
    • headache & decreased level of consciousness
    • headache and meningism
    • headache & abnormal physical signs e.g. fever
    TIAs
  • Migraine without aura
    • 5 attacks fulfilling BCDE
    • B) headache 4 to 72 hr
    • C) 2 of :- unilateral, pulsating, at least mod severe, worse on exercise
    • D) During headache at least 1 of : i) nausea &/or vomiting ii)photophobia & phonophobia
    • E) No evidence of related organic disease
    TIAs
  • Case history TIA vs migraine
    • 55 yr. old male Driving home heaviness, pins & needles R arm Cleared in 1/2 hr Then couldn’t read newspaper, garbled speech Jazzy effect R visual field next 2 hours Family h/o migraine
    TIA
  • TIA vs epilepsy
    • Ep positive motor/sensory phenomena
    • Spreads quickly over next minute
    • TIA +ve phenomena affect body parts simultaneously
    • Todds paralysis can follow partial or grand mal
    • Transient speech arrest - aimless staring, amnesia
    • dy/dx TIA & partial seizure can be difficult
    TIA
  • Case history TIA vs Epilepsy
    • 64 year old woman
    • 6 week h/o 20 attacks pins & needles R arm+leg
    • Lasted 5 mins
    • Start foot, spread affecting leg+arm over 1 min
    • Like water ‘running up my leg’
    • Each attack identical
    • CT Glioma left parietal lobe
    TIA
  • Transient global amnesia
    • Middle aged and elderly
    • Sudden disorder memory - appears ‘confused’
    • Anterograde & often retrograde amnesia few hr.
    • No other problems, patient can even drive
    • CVA amnestic syndrome if affects ant. thalamus Look for vert gaze palsy, c’spinal, spinothal, tract
    TIA
  • Intracranial structural lesions
    • Sometimes causes intermittent neurological symptoms (tumour, AVM, aneurysm)
    • 0.4% UK TIA/aspirin trial - intracranial tumour
    • Focal jerk/shake, sensory phenomena, loss consciousness, speech arrest.
    • Partial ep., vascular steal, ICP change, bleed
    TIA
  • TIAs - danger
    • Suspect brain tumour if :-
        • Pure sensory, esp c march of symptoms
        • Jerking of a limb during an attack
        • Loss of consciousness
        • Speech arrest
    TIAs
  • TIA vs structural lesion - case history
    • 78 year old woman
    • Multiple attacks weakness/clumsiness 4mths.
    • Lasted 10-45 mins
    • Aspirin, attacks continued
    • R frontal meningioma
    TIA
  • IC haemorrhage & others (i)
    • Small bleed may mimic TIA
    • Chronic subdural can  Aphasia, speech arrest. Headache 80%
    • MS - usually 3rd - 4th decade can present suddenly optic neuritis, unilateral myelitis, dystonic limb
    TIA
  • IC haemorrhage & others (ii)
    • Labyrinthine disorder - vertical nystagmus b’stem Menieres, BPV, B recurrent vertigo, viral labyrinth
    • Hypoglycaemia - can - transient hemiparesis
    • P Nerve lesion, myashtenia - brainstem TIA, psychological
    TIA
    • Syncope : loss consciousness /postural tone 2 0 ischaemia
    • Key to diagnosis sound clinical history & examination
    • Consciousness depends on ascending reticular activating system activating the two cerebral hemispheres
    TIA Non-focal sudden neurological deficits (i)
    • If a patient presents with syncope :
      • Exclude heart disease
          • Valvular eg. A Stenosis
          • HOCM
          • Conducting system
      • Exclude carotid sinus syndrome
      • Exclude epilepsy
    TIA Non-focal sudden neurological deficits (ii)
    • Transient unresponsiveness in the elderly
    • Drop attack - falling without warning
          • majority were cryptogenic, female x age 44 yr.
          • no loss of consciousness
          • no warning signs or symptoms
          • dy/dx vertebrobasilar insuff - diplopia, vertigo
    • Narcolepsy -cataplexy : sleepiness, loss of tone
    • Giddiness / dizziness
    TIA Non-focal sudden neurological deficits (iii)
  • TIA/mild CVA - strategy (i )
    • Early specialist referral
    • Identify and treat any specific disease (rare - e.g., an arteritis, SABE).
    • Anticoagulants in those with AFib (CAT scan)
    TIAs
  • TIA/mild CVA - strategy (ii)
    • Antiplatelet drugs
    • Modify vascular risk factors - BP, smoking, hyperlipidaemia
    • Select for duplex carotid scans the fewer still for arteriography the fewer still for endarterectomy .
    TIAs