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Transient Ischaemic Attack            

Title               

Ñ    Transient Ischaemic Attack           

Definition

Ñ    Acute

Ñ    Transient

Ñ    Focal loss of cerebral function

Of:

Ñ    Vascular origin

Features

Ñ    Usually rapid in onset, reaching maximum manifestations in less than 5 mins

Ñ    Usually precedes a stroke, especially if recurrent

Ñ    Needs urgent attention especially if recurrent:

> one in 24 hrs

Ñ    Must be considered a sign of generalised atherosclerotic disease

Pathogenesis

Causes

Internal Factors

Ñ    Cerebral embolism:

Left ventricular thrombus

Atrial fibrillation

Valvular disease

Mural Factors

Ñ    Atherosclerosis of carotid and vertebral arteries:

Most common cause of TIAs

Ñ    Arterial dissection

Ñ    Arteritis:

 Non-infectious necrotising vasculitis

 Drugs

 Irradiation

 Local trauma

Systemic Factors

Drugs

Ñ    Sympathomimetic drugs:

Cocaine

CVS

Ñ    Congenital heart disease with cerebral thromboembolism

Ñ    Vasculitis

HS

Ñ    Thrombophilia

Ñ    Myeloma

Ñ    Polycythaemia

Ñ    Sickle cell anaemia

LMS

Ñ    Marfan’s syndrome

Pathological Process

Ñ    Neuronal function adversely affected due to temporary cessation of blood flow

Clinical Features

History

Age

Ñ    Commoner in older people

E&M

Ñ    Fever

CNS

Ñ    Speech:

Dysarthria

Dysphasia

Ñ    Headaches

Ñ    Visual impairment

Ñ    Motor or sensory neurological deficit

Ñ    Seizures

Ñ    Confusion

Past Illnesses

Ñ    Previous ischaemic/ haemorrhagic strokes

Ñ    Previous TIAs

Ñ    Atrial fibrillation,

Ñ    Ischaemic heart disease

Ñ    Peripheral vascular disease

Ñ    Diabetes mellitus

Ñ    Hypertension

Ñ    Hyperlipidaemia

Ñ    Recent trauma

Ñ    Recent cardiac or carotid surgery

Family History

Ñ    Stroke

Ñ    Ischaemic heart disease

Ñ    Diabetes mellitus

Ñ    Hypertension

Ñ    Migraine

Ñ    Peripheral vascular disease

Examination

E&M

Ñ    Fever

CVS

Ñ    Cardiac arrhythmia

Ñ    Hypertension

Ñ    Peripheral vascular disease

Ñ    Carotid bruit

Ñ    Valvular heart disease

Ñ    Ischaemic heart disease

Ñ    Heart failure

CNS

Anterior Circulation

Ñ    Cognitive impairment

Ñ    Aphasia

Ñ    Visual impairment:

Amaurosis fugax

Hemianopia

Ñ    Hemiparesis

Ñ    Hemisensory loss

Posterior circulation

Ñ    Diplopia

Ñ    Vertigo

Ñ    Vomiting

Ñ    Ataxia

Ñ    Hemisensory loss

Ñ    Transient global amnesia

Ñ    Tetraparesis

Complications

Ñ    Completed ischaemic or haemorrhagic stroke

Investigations

Fluids

Blood

Haematology

Ñ    Polycythaemia

Ñ    Anaemia:

·          Occult GI blood loss:

Influences treatment

Ñ    Plasma viscosity:

Increased in vasculitis

Ñ    Folate deficiency:

Associated with hyperhomocystinaemia

Ñ    Thrombophilia screen:

·          Ischaemic stroke < 50 yrs:

Protein C, S deficiency

Biochemistry

Ñ    Blood glucose:

·          Random

·          Fasting:

If random > 7.0 mmol/L

Ñ    Fasting lipid profile

Ñ    Fasting homocysteine:

Ischaemic stroke < 50 yrs

Immunology

Ischaemic stroke < 50 yrs or raised plasma viscosity:

Ñ    Antiphospholipid antibody

Ñ    Lupus anticoagulant

Ñ    ENA, ANCA

Genetics

In ischaemic stroke < 50 yrs:

Ñ    Factor V Leiden defect

Ñ    Prothrombin G2021A mutation

Ñ    MELAS (mitochondrial encephalomyopathy, lactic acidosis, stroke-like episodes)

Imaging

Ultrasound

Ñ    Carotid ultrasound:

Within 48 hrs of TIA

Ñ    Echocardiogram:

ECG abnormal

Cardioembolism suspected

Ñ    Contrast echocardiogram:

·          PFO (patent foramen ovale) suspected:

CT brain shows ischaemic damage

CT Scan

Brain:

Ñ    Patients being considered for carotid endarterectomy

Ñ    Urgent CT Brain if anticoagulated

Ñ    To exclude intracranial space occupying lesions:

With contrast

Ñ    Exclude subdural haematoma

MRI

Ñ    Posterior circulation events

Ñ    MR Angiography:

Exclude dissection

Carotid bifurcation imaging difficult due to calcification

Ñ    TIAs more than a week old in patients who are anticoagulated

Electrophysiology

ECG

Ñ    Arrhythmia

Ñ    Ischaemic changes

Ñ    Left ventricular hypertrophy (LVH)

Ñ    24 hr ECG:

In patients who have:

·          Palpitations

·          Long-standing hypertension

·          LVH

Management

Control

Drugs

Ñ    Antiplatelets:

·          Aspirin 

·          Dipyridamole:

If CT brain shows evidence of ischaemic damage

·          Clopidogrel:

Aspirin intolerant

Ñ    Anticoagulants (warfarin):

Atrial fibrillation

LV (left ventricular) thrombus

LV hypokinesis

Ñ    Antilipid treatment:

Statins

Fibrates

Ezetimibe

Ñ    Antihypertensives

Ñ    Control of diabetes mellitus

Surgery

Ñ    Carotid endarterectomy:

Fit patients

> 70% stenosis of the internal carotid artery Within 2 weeks of symptoms

Lifestyle Adjustments

Ñ    Smoking:

Cessation

Ñ    Alcohol intake:

Within recommended limits

Ñ    Aerobic exercise:

20-30 mins at least thrice weekly

Ñ    Diet:

Less saturated fat

More fruits, vegetables, nuts, wholegrain, oily fish

Ñ    Lose weight

Prognosis

Ñ    Risk of stroke:

5-10% in first week

10-20% in 3 months

Ñ    Sign of generalised atherosclerotic disease

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