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  • Transient Ischaemic Attack

    Geoffrey Cloud

  • Which of the following have suffered a TIA?

    Transient RSW Transient LSW Transient RSW

  • DWI MR stroke footprint

  • Definition

    Sudden onset focal neurological disturbance

    lasting

  • Newer Definitions

    Transient episode of neurological dysfunctioncaused by focal brain, retinal or spinal cordischaemia without acute infarction

    AHA/ASA Definition 2009

    i.e. requires imaging

  • either way still..

  • How common is TIA?

    Uncertain

    under-reported/over diagnosed

    Incidence around 1.1 per 1000 per year in USor 0.66 in OXVASC

    Prevalence of 2.3% US (around 5M)

  • Is it a TIA? clinical clues

    Time course of Symptoms

    onset/offset

    Nature of Symptoms

    focal not general, relating to vascular territory

    Quality of Symptoms

    negative not positive

    Associated Symptoms

    atypical

  • TIA mimics

    Migraine

    Seizures

    Syncope

    Metabolic disturbance

    SOL

    Other neurological ( Bells palsy, TGA,peripheral nerve injury, vertigo)

  • Does TIA matter?

    10-15% of TIA cases have a stroke within thenext 3 months

    Half of strokes following TIA occur within48hrs

  • Stroke risk after TIA

    1707 emergency room

    presentations with TIA

    Follow-up 90 days

    180 (10.5%) stroke rate

    91 within first 2 days

    Johnston et al 2000 JAMA

  • Is this TIA patient at risk?

    Coull, Lovett and Rothwell, BMJ 2004

  • ABCD2 algorithm(1) predicts a patient's very early risk of stroke following a TIA.The score is calculated according to 5 important clinical features:

    Symbol Clinical feature Criterion Score

    A Age >= 60 1

    B Blood pressure >= 140/90 mmHg 1

    C Clinical features of the TIA unilateral weakness 2

    speech disturbance withoutweakness

    1

    D1 Duration of symptoms >= 60 min 2

    10-59 min 1

  • Investigating a TIA

    Brain imaging

    Extracranial vessel imaging

    Cardiac rhythm (+/- structure)

    Routine bloods including fasting lipids

  • Treatment strategies

    Treating modifiable vascular risk factors

    Reducing embolism

    cardiac

    artery to artery

  • Effect of carotid endarterectomy stratified bytime from last event to randomisation

    Ipsilateral ischaemic stroke and operative stroke or death

    32.7

    16.0

    11.2 9.413.8

    3.4

    0.0 -2.9

    -20.0

    -10.0

    0.0

    10.0

    20.0

    30.0

    40.0

    50.0

    0-2 2-4 4-12 12+

    Weeks between symptomatic event and randomisation

    AR

    R(%

    ),9

    5%

    CI

    70-99% 50-69%

    Lancet 2004; 363: 915-24

  • National CIA audit June 2011

  • Implications for Service Organisation

    Specialist service 7/7

    Responsive

    see, investigate and treat

    Neurovascular MDT pathway

    No RCTs of different types of TIA service

  • EXPRESS

    Lancet 2007,370,1432 - 1442

  • Other examples

    SOS TIA Lancet Neurol 2007;6:95360

    1085 pts (22% mimics, 5% stroke, 14 possible TIA)

    90 day stroke rate of 1.6% cf 6.5% predicted byABCD2 score

    Calgary rapid evaluation Can J Neurol Sci.2009Jul;36(4):450-5

    90 day stroke risk 5% in rapid evaluation cohort cf10% in standard

  • National Guidance

    Stroke strategy

    NICE

    ICSWP

    DH vital signs

  • Take home messages for TIA

    they are mini-strokes

    diagnosis is clinical but requires imaging

    risk stratification is important for organisationof services

    warrant urgent investigation and treatment

  • And dont forget to mention..

  • Transcranial Doppler (TCD) detection of EmbolicSignals

  • P = 0.0001P = 0.0037

    Ipsilateral TIA and strokeIpsilateral stroke

    N = 200

    Embolic symptoms predict stroke risk

    Time (days)

    9080706050403020100

    Cu

    mu

    lativ

    esu

    rviv

    alf

    ree

    of

    ipsi

    late

    rals

    tro

    ke

    1.05

    1.00

    .95

    .90

    .85

    .80

    .75

    .70

    .65

    .60

    .55

    .50

    Time (days)

    9080706050403020100

    Su

    rviv

    al

    fre

    eo

    fip

    sila

    tera

    lstr

    ok

    eo

    rT

    IA

    1.0

    1.0

    .9

    .9

    .8

    .8

    .8

    .7

    .7

    .6

    .6

    .5

    embolic signals

    emboli detected

    emboli detected

    -censored

    no emboli

    no emboli-censored

    MacKinnon and Markus

    Transient Ischaemic AttackSlide Number 2Slide Number 3Which of the following have suffered a TIA?DWI MR stroke footprintDefinitionNewer Definitionseither way still..Slide Number 9How common is TIA?Slide Number 11Is it a TIA? clinical cluesTIA mimicsDoes TIA matter?Stroke risk after TIAIs this TIA patient at risk?Slide Number 17Investigating a TIATreatment strategiesEffect of carotid endarterectomy stratified by time from last event to randomisationIpsilateral ischaemic stroke and operative stroke or death National CIA audit June 2011Implications for Service OrganisationEXPRESSOther examplesNational GuidanceTake home messages for TIAAnd dont forget to mention..Slide Number 28Slide Number 29