Tia

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  • Tia

    1. 1. Tia slides These slides require professional interpretation and are not for personal diagnosis or treatment. Consult your doctor if you need a medical opinion.
    2. 2. TIAs - size of the problem <ul><li>Incidence of new cases 42/100,000/yr </li></ul><ul><li>of which carotid TIAs is 34/100,000 </li></ul><ul><li>Incidence of first ever stroke 200/100,000/yr </li></ul><ul><li>The incidence of new strokes 240/100,000/yr </li></ul>TIAs
    3. 3. 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
    4. 4. 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
    5. 5. TIAs <ul><li>Catchment pop. of 250,000 there will be </li></ul><ul><li>100 new TIAs per year </li></ul><ul><li>up to another 170 'unknown to GP' </li></ul>TIAs
    6. 6. TIAs - key questions <ul><li>Is history consistent with TIA ? </li></ul><ul><li>Is TIA carotid or vertebrobasilar ? </li></ul><ul><li>Is TIA haemodynamic or embolic ? </li></ul><ul><li>What are p/ts risk factors for TIA ? </li></ul><ul><li>What are appropriate investigations & Rx ? </li></ul>TIAs
    7. 7. TIAs <ul><li>Risk of stroke </li></ul><ul><li>Aetiology </li></ul><ul><li>Diagnosis </li></ul><ul><li>Assessment and investigations </li></ul><ul><li>Risk factors </li></ul><ul><li>Treatment </li></ul>TIAs
    8. 8. TIA <ul><li>50% of TIAs go unreported </li></ul><ul><li>6-12% develop a stroke in the first year </li></ul><ul><li>then risk CVA about 5% annually </li></ul><ul><li>risk stroke highest first few weeks </li></ul><ul><li>only 15% CVAs have h/o TIA </li></ul>TIAs
    9. 9. TIA <ul><li>Risk death 6.3 - 8% per yr - RR x1.4 </li></ul><ul><li>25% of deaths stroke, 45% cardiac </li></ul><ul><li>Only 5-10% of TIA’s suitable for arterectomy </li></ul><ul><li>Aspirin may lead to 4% reduction strokes/yr - reduce incidence of CVA from 7% to 5% in patients with TIA (25%). </li></ul>TIAs
    10. 10. Annual risk CVA, MI, vascular death following TIA minor CVA <ul><li>CVA 6.7 % </li></ul><ul><li>MI 2.5 </li></ul><ul><li>Death 7.2 </li></ul><ul><li>CVA, MI, Vascular death 8.6 </li></ul><ul><li>CVA, MI, Death 10.3 </li></ul>TIAs
    11. 11. TIAs <ul><li>Risk of stroke </li></ul><ul><li>Aetiology </li></ul><ul><li>Diagnosis </li></ul><ul><li>Assessment and investigations </li></ul><ul><li>Risk factors </li></ul><ul><li>Treatment </li></ul>TIAs
    12. 12. TIAs - site <ul><li>10% vertebrobasilar </li></ul><ul><li>80% carotid </li></ul><ul><li>10% uncertain </li></ul><ul><li>17% are purely retinal (amaurosis fugax) better prognosis </li></ul>TIAs
    13. 13. TIAs Approximate frequencies of main causes of ischaemic stroke & presumably TIAs Rarities 5% Atherothromboembolism 50% Embolism - heart 20% Intracranial small vessel disease 25% TIAs
    14. 14. 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
    15. 15. Transient ischaemic attacks TIAs
    16. 16. Carotid TIAs <ul><li>Hemiparesis / hemisensory loss </li></ul><ul><li>Dysphasia </li></ul><ul><li>Apraxia </li></ul><ul><li>Visuospatial problems </li></ul><ul><li>Homonymous hemianopia </li></ul><ul><li>Amaurosis fugax </li></ul>TIAs
    17. 17. Amaurosis fugax <ul><li>Risk of CVA half that of a TIA with a cerebral event </li></ul>TIAs
    18. 18. Transient ischaemic attacks TIAs
    19. 19. Vertebrobasilar TIAs <ul><li>Vertigo, Vomiting, Ataxia </li></ul><ul><li>Diplopia - disorder of conjugate eye movement - vertical or horizontal </li></ul><ul><li>Cortical blindness or isolated hemianopia </li></ul><ul><li>Bilateral motor or sensory defect </li></ul><ul><li>Ipsilateral cranial nerve deficit and contralateral motor or sensory defect </li></ul>TIAs
    20. 20. TIAs <ul><li>Risk of stroke </li></ul><ul><li>Aetiology </li></ul><ul><li>Diagnosis </li></ul><ul><li>Assessment and investigations </li></ul><ul><li>Risk factors </li></ul><ul><li>Treatment </li></ul>TIAs
    21. 21. TIA - diagnosis <ul><li>The main 'diagnostic' tool for TIA is a careful clinical history Of referrals from GPs 38% in one study had a 'true' TIA, </li></ul><ul><li>10% migraine, 9% faints, 9% 'funny turns' </li></ul><ul><li>9% possible TIAs, 6% epilepsy, 6% vertigo </li></ul><ul><li>0.8% hypoglycaemia, 0.4% brain tumours </li></ul>TIAs
    22. 22. TIA - diagnostic criteria (i) <ul><li>Focal neurological or monocular symptoms </li></ul><ul><li>-ve symptom (weak-numb-dysphasia-visual loss) </li></ul><ul><li>rare +ve (paraesthesia, limb shaking, flashes light) </li></ul><ul><li>abrupt onset secs, no march or intensification </li></ul><ul><li>resolve gradually but completely, 1 hr, lasting for seconds rare - ? Afib </li></ul>TIA
    23. 23. TIA - diagnostic criteria (ii) <ul><li>usually no warning - ?Ep, migraine or provocation </li></ul><ul><li>headache may occur during or after </li></ul><ul><li>loss consciousness rare - ?Ep, syncope </li></ul><ul><li>frequent stereotyped attacks suggest partial Ep </li></ul>TIA
    24. 24. TIA - symptoms (i) <ul><li>Unilateral weakness/heaviness/clumsiness 50% </li></ul><ul><li>Unilateral sensory symptoms 35 </li></ul><ul><li>Slurred speech 23 </li></ul><ul><li>Transient monocular blindness 18 </li></ul><ul><li>Difficulty speaking (dysphasia) 18 </li></ul><ul><li>Unsteadiness (ataxia) 12 </li></ul>TIA
    25. 25. TIA - symptoms (ii) <ul><li>Dizziness (vertigo) 5% </li></ul><ul><li>Homonymous hemianopia 5 </li></ul><ul><li>Double vision 5 </li></ul><ul><li>Bilateral limb weakness 4 </li></ul><ul><li>Dysphagia 1 </li></ul><ul><li>Crossed motor and sensory loss 1 </li></ul>TIA
    26. 26. TIAs <ul><li>Risk of stroke </li></ul><ul><li>Aetiology </li></ul><ul><li>Diagnosis </li></ul><ul><li>Assessment and investigations </li></ul><ul><li>Risk factors </li></ul><ul><li>Treatment </li></ul>TIAs
    27. 27. Carotid bruit <ul><li>Can’t be used to determine if symptomatic patients have ICA stenosis amenable to surgery. </li></ul>TIAs
    28. 28. Carotid bruit <ul><li>4% all > 45 years </li></ul><ul><li>26 - 53% symptomatic pts </li></ul><ul><li>10% bruit, no stenosis </li></ul><ul><li>71% severe stenosis, no bruit </li></ul><ul><li>30% ICA occlusion - bruit - ? ECA </li></ul>TIAs
    29. 29. Carotid bruit + TIA <ul><li>40% carotid TIA localised stenosis </li></ul><ul><li>Increases if TIA’s brief bruit amaurosis fugax too </li></ul><ul><li>10% may have complete occlusion </li></ul><ul><li>Risk CVA up to 10 % yr 1, death IHD 10%/yr </li></ul>TIAs
    30. 30. Carotid bruit <ul><li>Stroke rate, asymptomatic - 0.6% /yr asymptomatic, bruit - 2.7% /yr symptomatic ICA - 10 % /yr </li></ul><ul><li>Bruit : 0.6 - 2.4% develop TIA </li></ul><ul><li>Stroke side does not always equate with bruit side </li></ul>TIAs
    31. 31. Carotid bruit <ul><li>Increased risk of stroke, myocardial infarction and death. </li></ul><ul><li>Bruits are absent in > 1/3 patients with high grade stenosis. </li></ul><ul><li>10% of patients with less than 50% stenosis will have a bruit. </li></ul><ul><li>Bruit does not select out those who need endarterectomy. </li></ul>TIAs
    32. 32. TIAs - routine investigations <ul><li>FBP </li></ul><ul><li>ESR/CRP, +/- plasma viscosity </li></ul><ul><li>U&E, blood sugar </li></ul><ul><li>Serum cholesterol - TFTs </li></ul><ul><li>ECG </li></ul>TIAs
    33. 33. TIA - who to duplex scan (i) ? <ul><li>Symptomatic in carotid territory (TIA or non-disabling CVA) </li></ul><ul><li>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%) </li></ul>TIAs
    34. 34. TIA - who to duplex scan (ii) ? <ul><li>Recent symptoms (past 6 months) </li></ul><ul><li>No other life threatening disease </li></ul><ul><li>No marked pulmonary/airways disease </li></ul><ul><li>No uncontrolled hypertension, cardiac failure or ischaemic heart disease </li></ul><ul><li>No clinically significant dementia </li></ul>TIAs
    35. 35. TIA - who to duplex scan (iii) ? <ul><li>No marked frailty </li></ul><ul><li>No marked generalised arteriopathy </li></ul><ul><li>No significant chronic liver or renal disease </li></ul>TIAs
    36. 36. EEG, CT and MRI in TIA <ul><li>Not indicated monocular </li></ul><ul><li>CT if > 1 TIA esp. carotid, arterectomy </li></ul><ul><li>Consider MRI if vertebrobasilar continuing & CT no help </li></ul><ul><li>EEG if in doubt - 35% c Ep always abnormal 50% occasionally 15% never </li></ul>TIAs
    37. 37. TIAs <ul><li>Risk of stroke </li></ul><ul><li>Aetiology </li></ul><ul><li>Diagnosis </li></ul><ul><li>Assessment and investigations </li></ul><ul><li>Risk factors </li></ul><ul><li>Treatment </li></ul>TIAs
    38. 38. Stroke - risk factors <ul><li>Age * </li></ul><ul><li>Male </li></ul><ul><li>BP* - causal </li></ul><ul><li>Smoking x 1.5 esp SAH </li></ul><ul><li>Fibrinogen </li></ul><ul><li>Diabetes x 2 * </li></ul><ul><li>Black / SE Asian </li></ul><ul><li>Social deprivation </li></ul><ul><li>MI / angina + </li></ul><ul><li>Cardiac failure + </li></ul><ul><li>LVH </li></ul><ul><li>A Fib - x 6, x 18 M Sten </li></ul><ul><li>Claudication + </li></ul><ul><li>Carotid bruit </li></ul><ul><li>TIA x 5 - x 10 </li></ul>TIAs
    39. 39. Stroke - prevalence of vascular risk factors - first time ever cerebral infarct <ul><li>BP > 160/90 52 % </li></ul><ul><li>Angina or MI 38 </li></ul><ul><li>Current smoker 27 </li></ul><ul><li>Claudication/ no foot pulses 25 </li></ul><ul><li>Major cardiac embolic source 20 </li></ul><ul><li>TIA 14 </li></ul><ul><li>Cx arterial bruit 14 </li></ul><ul><li>Diabetes mellitus 10 </li></ul>Any of = 80% TIAs
    40. 40. Risk CVA, MI, vascular death following TIA minor CVA <ul><li>PVD 2.31 </li></ul><ul><li>Carotid & vertebral TIAs 2.03 </li></ul><ul><li>Male 1.98 </li></ul><ul><li>Residual neurological signs 1.93 </li></ul><ul><li>Age 1.82 </li></ul><ul><li>TIA brain vs eye 1.75 </li></ul><ul><li>LVH 1.72 </li></ul><ul><li>Number of TIAs past year 1.16 </li></ul>TIAs
    41. 41. TIA - risk of further CVA <ul><li>A CVA rather than a TIA </li></ul><ul><li>Frequent TIAs </li></ul><ul><li>Ulcerated plaque - soft plaque </li></ul><ul><li>Stenosis above 80% are all associated with a greater stroke risk </li></ul>TIAs
    42. 42. TIAs <ul><li>Risk of stroke </li></ul><ul><li>Aetiology </li></ul><ul><li>Diagnosis </li></ul><ul><li>Assessment and investigations </li></ul><ul><li>Risk factors </li></ul><ul><li>Treatment </li></ul>TIAs
    43. 43. TIA - hospital admission <ul><li>Symptoms suggestive CVA > 1hr. </li></ul><ul><li>> 2 TIAs in 1 week </li></ul><ul><li>Pyrexia + TIA </li></ul><ul><li>Severe hypertension + TIA </li></ul><ul><li>Atrial fibrillation, recent MI + TIA </li></ul>TIAs
    44. 44. TIAs <ul><li>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). </li></ul>TIAs
    45. 45. 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
    46. 46. Aspirin - TIA & Stroke <ul><li>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) </li></ul>TIAs
    47. 47. Drugs & ischaemic stroke <ul><li>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 </li></ul><ul><li>Clopidrogel - Caprie study, edge over aspirin (0.05% difference, 1:200) </li></ul><ul><li>Aspirin + persantin - ESPS2 study combination x2 effect of single. </li></ul>TIAs
    48. 48. Aspirin <ul><li>Apparently healthy men </li></ul><ul><ul><li>C-reactive protein > 2.1 mg/l :- </li></ul></ul><ul><ul><ul><li>risk stroke double </li></ul></ul></ul><ul><ul><ul><li>risk MI tripled </li></ul></ul></ul><ul><ul><ul><ul><li>aspirin decreased this xs risk by 53% </li></ul></ul></ul></ul>NEJM 1997; 336: 973-9.
    49. 49. 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.
    50. 50. CAPRIE - Clopidrogel <ul><li>Inhibits ADP-platelet aggregration </li></ul><ul><li>Recent stroke , M Infarct, PVD n = 19,185: 1-3 yr, x = 1.91 yr. </li></ul><ul><ul><li>Clopidrogel 75mg vs aspirin 325 mg </li></ul></ul><ul><ul><li> 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) </li></ul></ul>Lancet 1997; 348: 1329-39
    51. 51. Aspirin secondary prevention <ul><li>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). </li></ul><ul><li>Aspirin reduces recurrent stroke by around 25%. </li></ul>TIAs
    52. 52. European stroke prevention study 2 <ul><li>Mild stroke or TIA, 2 yr follow up </li></ul><ul><li>Stroke risk (or death) 18% (13%) c aspirin </li></ul><ul><li> 16% (15%) c persantin retard </li></ul><ul><li> 37% (24%) with both </li></ul>TIAs
    53. 53. CAPRIE study <ul><li>Recent ischaemic stroke, MI or symptomatic peripheral arterial disease </li></ul><ul><li>Follow-up 1-3 years </li></ul><ul><li>Risk ischaemic CVA, MI, vascular death Clopidrogel 5.3% per yr. Aspirin 5.8% per yr. </li></ul><ul><li>Drop out 21%, age 62.5 yr </li></ul><ul><li>(Antiplatelets Trialist’s Collab. Asp decr 25%) </li></ul>TIAs
    54. 54. Drugs & ischaemic stroke/TIA - arterial <ul><li>Recommendations </li></ul><ul><ul><ul><li>TIA/CVA non cardioembolic - aspirin is the standard </li></ul></ul></ul><ul><ul><ul><li>Consider aspirin + Persantin retard </li></ul></ul></ul><ul><ul><ul><li>Conside Clopidrogel if reactions to above drugs </li></ul></ul></ul><ul><ul><ul><li>? Clopidrogel niche in peripheral vascular disease </li></ul></ul></ul><ul><ul><ul><li>Significant carotid stenosis - arterectomy if suitable </li></ul></ul></ul><ul><ul><ul><li>Embolic stroke/TIA - consider warfarin </li></ul></ul></ul>TIAs
    55. 55. Carotid stenosis <ul><li>70 - 99% 10%/yr - CVA </li></ul><ul><li>Willing for surgery </li></ul><ul><li>Carotid TIA last few weeks/month </li></ul><ul><li>No significant intracranial arterial disease </li></ul><ul><li>Fit for surgery - BP, MI, IHD, LVF/CHF </li></ul>TIAs
    56. 56. Carotid endarterectomy <ul><li>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 </li></ul>TIAs
    57. 57. Endarterectomy - TIAs <ul><li>Aspirin decrease incidence CVA 25% 7 to 5% </li></ul><ul><li>Endarterectomy abolishes ipsilateral stroke </li></ul><ul><li>11-12% TIA’s consideration for arterectomy </li></ul><ul><li>Arterectomy decrease incidence stroke by 1% </li></ul><ul><li>Indicated symptomatic stenosis 70-99% </li></ul><ul><li>Mortality arterectomy < 3% </li></ul>TIAs
    58. 58. Endarterectomy - guidelines <ul><li>Asymptomatic bruit & > 60% stenosis in men, or in men & women if severe contralateral stenosis. </li></ul><ul><li>Endarterectomy halves the risk of stroke in those with severe asymptomatic stenosis, absolute risk of stroke low & surgery is usually not indicated. </li></ul><ul><li>Severe symptomatic stenosis (greater than 70%) in men and women. Risk of stroke is highest within weeks or months of the ischaemic event. </li></ul>TIAs
    59. 59. Symptomatic carotid stenosis <ul><li>NASCET trial risk ipsilateral CVA at 2 years :- 26% for medical Rx 9% for surgical Rx </li></ul><ul><li>At 5 years risk of ipsilateral CVA 10% risk of any stroke 18% risk of death 27% In those Rx surgically. </li></ul><ul><li>Endarterectomy decreases risk CVA by x6 - x10 </li></ul>TIAs
    60. 60. Symptomatic carotid stenosis <ul><li>10 arterectomies will save 1 stroke </li></ul><ul><li>Incidence of stroke reduction < 1% </li></ul><ul><li>Still cost efficient </li></ul>TIAs
    61. 61. Asymptomatic carotid stenosis (ACS) <ul><li>Of 50% present in 25% hypertensives </li></ul><ul><li>Of 50% present in 12% p. vasc disease </li></ul><ul><li>Smoker c  lipids, IHD, AAA, ACS likely </li></ul><ul><li>TIA, CVA more likely c soft plaque </li></ul><ul><li>>50% stenosis 7% risk CVA 2 years </li></ul><ul><li>>50% stenosis & BP 1/3 CVA 5 years </li></ul><ul><li>Soft plaque < 75%, 20% CVA TIA 3 years </li></ul>TIAs
    62. 62. Asymptomatic carotid stenosis <ul><li>30% > 50 yr have some carotid artery disease </li></ul><ul><li>Stenosis > 50% in 4% middle aged & elderly </li></ul><ul><li>< 1% middle aged & elderly stenosis > 80% </li></ul><ul><li>Asymptomatic stenosis > 75% Risk ipsilateral CVA 2.5% per year (1% < 75%) Risk fatal coronary heart disease 6.5% per year </li></ul><ul><li>5 yr medical Rx risk CVA 10.6% </li></ul><ul><li>5 year surgical risk CVA 5.8% </li></ul>TIAs
    63. 63. TIAs - practical points (1) <ul><li>Acute focal neurological defect monocular, clears 24 hr, usually half hr. </li></ul><ul><li>30% c TIA get CVA by 5 years </li></ul><ul><li>Global symptoms in isolation rarely due to TIA loss consciousness, presyncope, dizziness, confusion, incontinence </li></ul><ul><li>Presence/absence carotid bruit ‘unhelpful’ for diagnosing significant carotid disease </li></ul>TIAs
    64. 64. TIAs - practical points (2) <ul><li>Investigation include FBP, ESR, BS, lipids, ECG </li></ul><ul><li>Admit crescendo TIAs - occurring daily or > </li></ul><ul><li>Treat risk factors - AF, BP, smoking, C2H5, lipids </li></ul><ul><li>Antiplatelet therapy - 25%  CVA / MI/ vasc  </li></ul><ul><li>Warfarin for AF </li></ul><ul><li>Endarterectomy for selected pts. </li></ul>TIAs
    65. 65. TIAs - dy/dx - transient deficit <ul><li>Migraine </li></ul><ul><li>Epilepsy </li></ul><ul><li>Intracranial tumour (up to 1 ‘TIAs’) </li></ul><ul><li>Syncope </li></ul><ul><li>Subdural </li></ul><ul><li>Hypoglycaemia </li></ul><ul><li>Demyelination </li></ul><ul><li>IC bleed - but usually lasts days </li></ul>TIAs
    66. 66. dy/dx TIA <ul><li>Was the event vascular - very likely if </li></ul><ul><li>Signs SABE </li></ul><ul><li>Carotid territory + focal loud long ipsilateral bruit </li></ul><ul><li>M Infarct last 3-4 weeks </li></ul><ul><li>Rheumatic atrial fibrillation </li></ul>TIA
    67. 67. dy/dx TIA <ul><li>Was the event vascular - likely if </li></ul><ul><li>A fib & NR valvular heart disease </li></ul><ul><li>Arterial bruit anywhere </li></ul><ul><li>Prosthetic heart valve & on warfarin </li></ul>TIA
    68. 68. dy/dx TIA <ul><li>Was the event vascular - unlikely </li></ul><ul><li>< 40, years </li></ul><ul><li>no vascular risk factors </li></ul><ul><li>no symptomatic vascular disease </li></ul>TIA
    69. 69. dy/dx TIAs <ul><li>attack usually lasts < 60 min, therefore </li></ul><ul><li>diagnosis relies on clinical history </li></ul><ul><li>BUT history/memory of event may be poor </li></ul><ul><li>diagnosis open to inter/intra-observer variation </li></ul><ul><li>so let’s concentrate on serious but remediable differential diagnoses </li></ul>TIA
    70. 70. <ul><li>Breakdown of transient neurological symptoms Oxford Community Stroke Project </li></ul><ul><li>39% TIAs </li></ul><ul><li>10.4% migraine </li></ul><ul><li>9.6% syncope </li></ul><ul><li>9.0% funny turn </li></ul><ul><li>6.6% isolated vertigo </li></ul>dy/dx TIA <ul><li>5.8% epilepsy </li></ul><ul><li>3.4% TG amnesia </li></ul><ul><li>< 1% isolated diplopia </li></ul><ul><li>< 1% drop attack </li></ul><ul><li>12% possible TIA </li></ul>TIA
    71. 71. dy/dx TIA <ul><li>Possible causes transient neurological symptoms </li></ul><ul><li>Focal ischaemia* + SA Labyrinthine disease* </li></ul><ul><li>Migraine aura* Metabolic, Gluc + , Ca, Na </li></ul><ul><li>Partial (focal) epilepsy* Peripheral nerve </li></ul><ul><li>TGA* + - Myasthenia </li></ul><ul><li>Intracranial lesion Psychological </li></ul><ul><li>MS Key : *commonest + most impt </li></ul>TIA
    72. 72. Migraine vs TIA (i) <ul><li>Younger pt +/- family history </li></ul><ul><li>Positive focal cerebral/visual aura </li></ul><ul><li>Aura develops over 5-20 min, lasts < 60 min </li></ul><ul><li>Homonymous, unilateral or central visual c/o Zig zag, Fortification spectra, Scintillations </li></ul>TIA
    73. 73. Migraine vs TIA (ii) <ul><li>Somatosensory or motor paraesthesia/heaviness Evolve and spread over a period of minutes e.g.. arm., face, tongue </li></ul><ul><li>Headache, nausea, photo, phonophobia cin 1 hr </li></ul><ul><li>Headache usually lasts 4 - 72 hr </li></ul>TIA
    74. 74. Migraine with aura <ul><li>2 attacks fulfilling B & C </li></ul><ul><li>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 </li></ul><ul><li>C) No evidence of related organic disease </li></ul>TIAs
    75. 75. Danger signs for ‘migraine’ <ul><li>sudden onset of ‘worst ever headache’ </li></ul><ul><li>progressive course </li></ul><ul><li>onset with exertion </li></ul><ul><li>onset of headache during or after middle age </li></ul><ul><li>headache & decreased level of consciousness </li></ul><ul><li>headache and meningism </li></ul><ul><li>headache & abnormal physical signs e.g. fever </li></ul>TIAs
    76. 76. Migraine without aura <ul><li>5 attacks fulfilling BCDE </li></ul><ul><li>B) headache 4 to 72 hr </li></ul><ul><li>C) 2 of :- unilateral, pulsating, at least mod severe, worse on exercise </li></ul><ul><li>D) During headache at least 1 of : i) nausea &/or vomiting ii)photophobia & phonophobia </li></ul><ul><li>E) No evidence of related organic disease </li></ul>TIAs
    77. 77. Case history TIA vs migraine <ul><li>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 </li></ul>TIA
    78. 78. TIA vs epilepsy <ul><li>Ep positive motor/sensory phenomena </li></ul><ul><li>Spreads quickly over next minute </li></ul><ul><li>TIA +ve phenomena affect body parts simultaneously </li></ul><ul><li>Todds paralysis can follow partial or grand mal </li></ul><ul><li>Transient speech arrest - aimless staring, amnesia </li></ul><ul><li>dy/dx TIA & partial seizure can be difficult </li></ul>TIA
    79. 79. Case history TIA vs Epilepsy <ul><li>64 year old woman </li></ul><ul><li>6 week h/o 20 attacks pins & needles R arm+leg </li></ul><ul><li>Lasted 5 mins </li></ul><ul><li>Start foot, spread affecting leg+arm over 1 min </li></ul><ul><li>Like water ‘running up my leg’ </li></ul><ul><li>Each attack identical </li></ul><ul><li>CT Glioma left parietal lobe </li></ul>TIA
    80. 80. Transient global amnesia <ul><li>Middle aged and elderly </li></ul><ul><li>Sudden disorder memory - appears ‘confused’ </li></ul><ul><li>Anterograde & often retrograde amnesia few hr. </li></ul><ul><li>No other problems, patient can even drive </li></ul><ul><li>CVA amnestic syndrome if affects ant. thalamus Look for vert gaze palsy, c’spinal, spinothal, tract </li></ul>TIA
    81. 81. Intracranial structural lesions <ul><li>Sometimes causes intermittent neurological symptoms (tumour, AVM, aneurysm) </li></ul><ul><li>0.4% UK TIA/aspirin trial - intracranial tumour </li></ul><ul><li>Focal jerk/shake, sensory phenomena, loss consciousness, speech arrest. </li></ul><ul><li>Partial ep., vascular steal, ICP change, bleed </li></ul>TIA
    82. 82. TIAs - danger <ul><li>Suspect brain tumour if :- </li></ul><ul><ul><ul><li>Pure sensory, esp c march of symptoms </li></ul></ul></ul><ul><ul><ul><li>Jerking of a limb during an attack </li></ul></ul></ul><ul><ul><ul><li>Loss of consciousness </li></ul></ul></ul><ul><ul><ul><li>Speech arrest </li></ul></ul></ul>TIAs
    83. 83. TIA vs structural lesion - case history <ul><li>78 year old woman </li></ul><ul><li>Multiple attacks weakness/clumsiness 4mths. </li></ul><ul><li>Lasted 10-45 mins </li></ul><ul><li>Aspirin, attacks continued </li></ul><ul><li>R frontal meningioma </li></ul>TIA
    84. 84. IC haemorrhage & others (i) <ul><li>Small bleed may mimic TIA </li></ul><ul><li>Chronic subdural can  Aphasia, speech arrest. Headache 80% </li></ul><ul><li>MS - usually 3rd - 4th decade can present suddenly optic neuritis, unilateral myelitis, dystonic limb </li></ul>TIA
    85. 85. IC haemorrhage & others (ii) <ul><li>Labyrinthine disorder - vertical nystagmus b’stem Menieres, BPV, B recurrent vertigo, viral labyrinth </li></ul><ul><li>Hypoglycaemia - can - transient hemiparesis </li></ul><ul><li>P Nerve lesion, myashtenia - brainstem TIA, psychological </li></ul>TIA
    86. 86. <ul><li>Syncope : loss consciousness /postural tone 2 0 ischaemia </li></ul><ul><li>Key to diagnosis sound clinical history & examination </li></ul><ul><li>Consciousness depends on ascending reticular activating system activating the two cerebral hemispheres </li></ul>TIA Non-focal sudden neurological deficits (i)
    87. 87. <ul><li>If a patient presents with syncope : </li></ul><ul><ul><li>Exclude heart disease </li></ul></ul><ul><ul><ul><ul><li>Valvular eg. A Stenosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>HOCM </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Conducting system </li></ul></ul></ul></ul><ul><ul><li>Exclude carotid sinus syndrome </li></ul></ul><ul><ul><li>Exclude epilepsy </li></ul></ul>TIA Non-focal sudden neurological deficits (ii)
    88. 88. <ul><li>Transient unresponsiveness in the elderly </li></ul><ul><li>Drop attack - falling without warning </li></ul><ul><ul><ul><ul><li>majority were cryptogenic, female x age 44 yr. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>no loss of consciousness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>no warning signs or symptoms </li></ul></ul></ul></ul><ul><ul><ul><ul><li>dy/dx vertebrobasilar insuff - diplopia, vertigo </li></ul></ul></ul></ul><ul><li>Narcolepsy -cataplexy : sleepiness, loss of tone </li></ul><ul><li>Giddiness / dizziness </li></ul>TIA Non-focal sudden neurological deficits (iii)
    89. 89. TIA/mild CVA - strategy (i ) <ul><li>Early specialist referral </li></ul><ul><li>Identify and treat any specific disease (rare - e.g., an arteritis, SABE). </li></ul><ul><li>Anticoagulants in those with AFib (CAT scan) </li></ul>TIAs
    90. 90. TIA/mild CVA - strategy (ii) <ul><li>Antiplatelet drugs </li></ul><ul><li>Modify vascular risk factors - BP, smoking, hyperlipidaemia </li></ul><ul><li>Select for duplex carotid scans the fewer still for arteriography the fewer still for endarterectomy . </li></ul>TIAs

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