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Transient ischaemic attacks

Medicine > Cardiovascular

Background knowledge 🧠

Definition

  • Transient ischaemic attack (TIA) is a temporary period of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia without acute infarction.
  • Symptoms usually last less than 24 hours and often resolve within an hour.
  • TIA is a warning sign of potential future stroke.

Epidemiology

  • Incidence: Approximately 50 per 100,000 person-years.
  • More common in older adults, particularly those over 60 years.
  • Higher prevalence in males compared to females.
  • Risk factors include hypertension, diabetes, smoking, hyperlipidaemia, and atrial fibrillation.

Aetiology and Pathophysiology

  • Atherosclerosis (most common cause).
  • Embolism (from heart or extracranial arteries).
  • Small vessel disease.
  • Hypercoagulable states.
  • Pathophysiology: transient reduction in blood flow to the brain, leading to temporary neurological deficits.

Clinical Features 🌡️

Symptoms

  • Sudden onset of focal neurological deficits.
  • Weakness or numbness of face, arm, or leg (typically one side).
  • Dysphasia (difficulty speaking).
  • Visual disturbances (e.g., monocular blindness, hemianopia).
  • Dizziness, loss of balance or coordination.
  • Symptoms resolve within 24 hours.

Signs

  • Transient neurological signs (weakness, numbness, speech difficulties).
  • Normal neurological examination between episodes.
  • Possible carotid bruit on auscultation.
  • No permanent neurological deficits.

Investigations 🧪

Tests

  • CT or MRI brain to rule out stroke or other pathology.
  • Carotid Doppler ultrasound to assess for stenosis.
  • ECG to detect atrial fibrillation.
  • Echocardiography if embolic source suspected.
  • Blood tests: full blood count, glucose, lipids, clotting profile.
  • Consider Holter monitor for intermittent arrhythmias.

Management 🥼

Management

  • Immediate assessment and management to prevent stroke.
  • Antiplatelet therapy (e.g., aspirin, clopidogrel).
  • Anticoagulation if atrial fibrillation present (e.g., DOACs).
  • Carotid endarterectomy if significant carotid stenosis.
  • Management of risk factors (e.g., hypertension, diabetes, hyperlipidaemia).
  • Lifestyle modifications (smoking cessation, exercise, diet).

Complications

  • Increased risk of stroke within the first 48 hours.
  • Recurrent TIAs.
  • Permanent neurological deficits if progression to stroke.
  • Cardiovascular complications (e.g., myocardial infarction).
  • Decreased quality of life due to anxiety about recurrence.

Prognosis

  • High risk of stroke, especially within the first 48 hours after TIA.
  • Long-term prognosis depends on underlying aetiology and risk factor management.
  • Proactive management can reduce risk of future strokes.
  • Regular follow-up and monitoring are essential.

Key Points

  • TIA is a medical emergency and predictor of stroke.
  • Rapid assessment and management are crucial.
  • Management focuses on preventing future strokes.
  • Control of risk factors and lifestyle modifications are essential.
  • Multidisciplinary approach improves outcomes.

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Cardiovascular