Transient Ischaemic Attack

Nin BajajConsultant Neurologist

QMC & DRI

Definitions

• presumed to be due to thromboembolic vascular disease

• majority of episodes last less than 30 minutes [Warlow and Davenport, 1996; Rodgers, 1998].

• source most commonly the carotid arteries, the heart (particularly in people with AF), the aorta, or the vertebrobasilar arteries

• defined as the sudden onset of a focal cerebral or retinal deficit that recovers within 24 hours

Definitions• incidence is 0.42 per 1000 population

[Rodgers, 1998]

• GP with a list size of 2000 people will see five new people with a TIA or a stroke each year [Eccles et al, 1998].

• ~15% of people who suffer their first ever stroke have had preceding TIAs [Warlow and Davenport, 1996].

Clinical Presentation

– carotid territory occurs in 80% – may cause weakness or sensory symptoms

affecting an arm, leg, or one side of the face; also monocular visual loss (amaurosis fugax), dysphasia, or dysarthria

– vertebrobasilar territory in 20% – may cause a hemiparesis, hemisensory

symptoms, homonymous hemianopia, bilateral blindness, diplopia, vertigo, vomiting, dysarthria, dysphagia, or ataxia

Clinical Presentation

• Global symptoms by themselves are rarely due to TIA (e.g. unsteadiness, dizziness, syncope)

• Examination is usually normal

• but may provide evidence of risk factors (e.g. hypertension, carotid bruits, or atrial fibrillation)

• bruits are an unreliable guide to the presence or severity of carotid stenosis; severe stenosis may cause no bruit.

[Rothwell and Warlow, 1997; DTB, 1998]

Differential Diagnosis• Migrainous aura • Retinal or vitreous haemorrhage • Giant cell arteritis • Focal epileptic seizure • Intracranial lesion (e.g. tumour, subdural haematoma) • Multiple sclerosis • Labyrinthine disorders • Peripheral nerve lesions • Transient global amnesia • Psychological disorders (including hyperventilation) • Metabolic disturbance (e.g. hypoglycaemia) • [Warlow and Davenport, 1996; SIGN, 1997a]

Differentials

• Migraine• See patient SF• Usually headache/muzzy head, nausea,

photphobia/phonophobia, lethargy/malaise• Sometimes visual aura• Acephalic variants with persistent

sensory/motor aura or speech aura are the difficulties- this tends to last hours/days

Differentials

• Focal Epileptic seizure• If motor, repetitive stereotyped

movements with Jacksonian march• If sensory, positive rather than

negative phenomenon, lasts seconds not minutes, many episodes without resulting in stroke

Differential

• Intracranial lesion• These tend to give persistent

regional symptoms e.g. hemiplegia• If transient, tends to be due to focal

seizures• AVM can present a theoretical

problem but again should give many episodes without resulting in stroke

Differential

• Multiple Sclerosis• See patient LC• Tends to give symptoms over

weeks/months• Positive not negative symptoms• May not be simply carotid/vb

territories e.g. transverse myelitis

Differential

• Transient Global Amnesia• Associated with migraine, rarely epilepsy• Most often, psychological stress• Tends to last hours, often most of the day• Tend not to be confused but just forget

names, dates etc• Can usually find their way home!

Differential

• Brain. 1990 Jun;113 ( Pt 3):639-57. The aetiology of transient global amnesia. A case-control study of 114 cases with prospective follow-up. Hodges JR, Warlow CP

• Looked at 114 TGA & 212 TIA patients with normal controls for each

• None of the TGA patients had CVS risk factors• Actuarial analysis showed striking difference in life

expectancy• 7% of TGA patients go on to develop epilepsy

within 1 year• Migraine is associated with TGA

Case history 1

• LC• 48 yo lady• Originally seen 10 years before• C/o short lasting episodes of

paraesthesiae right arm, 10 minutes each time, frequent

• Further few episodes of speech going funny, lasting 15 min

LC

• Episodes of tingling & wobbliness of legs

• No fam hx of migraine • Clinical exam 10 years ago- mild

right arm weakness• MRI-wm change• Trimodal evoked- normal

LC

• Lp-normal, no OCB• Low positive anti-cardiolipin titre• Started on aspirin but told had “ms”• Negative for Lhermitte’s and Uthoff’s• Previously episodes of visual

teichopsia, photophobia, phonophobia

LC

• Currently, episodes of visual blurring with nausea & fatigue

• Paraesthesiae (R) arm, 1-2 /month• Clinical exam normal• MRI films• Video

LC

• Echo- PFO with right to left shunt• Percutaneous closure Oct 2004• Warfarinised for a while• Now feels “fantastic”- no episodes of

slow, slurred speech or head muzziness (was this ischaemic migraine?)

• No new wm lesions on follow-up MRI

SF

• 45 yo migraineur• Admitted 7/12/04 with bad migraine• Since age 21• Has 4/yr• Usually catamenial• Often left front-temporal headache

with left sided facial tingling & photophobia

SF

• Sometimes left sided arm weakness• Sometimes word finding problems• This time- sudden onset left sided

headache 28.11.04 (usually headache onset slow)

• Slurred speech• S/B GP and given amitriptyline

SF

• No relief• GP sent to A & E• CT brain reported normal• Discharged• 2/7 after CT, right sided weakness• CT & MRI

SF

• Strong hx CVA• 2 x Maternal aunts (30/40) and

maternal grandmother (32)• Mother migraineur• No hx miscarriage• Ex-smoker

SF

• O/e• Horner’s LHS• Right sided hemiplegia• MRI- left postero-frontal infarct• MRA- complete occlusion of left ICA

shortly after it’s origin• Thrombophilia screen negative