Transient Ischemic Attack: A Comprehensive Guide for Junior Doctors

Transient Ischemic Attack (TIA) is a crucial topic in emergency medicine due to its potential as a warning sign for a future stroke. As junior doctors, understanding the nuances of history taking, examination, investigation, and management can make a significant difference in patient outcomes. Let's break it down step by step.

History Taking: Key Questions

When assessing a patient with a suspected TIA, your history taking should focus on:

·     Symptom Onset and Duration:

·      Ask: "When did your symptoms start?" and "How long did they last?"

·      TIAs typically last less than 24 hours, often only a few minutes.

·     Symptom Nature and Progression:

·      Inquire: "Can you describe your symptoms?"

·      Common symptoms include sudden onset of weakness, numbness, speech difficulties, or visual disturbances.

·     Previous Episodes:

·      Ask: "Have you had similar symptoms before?"

·      Multiple TIAs can indicate a higher risk of stroke.

·     Associated Symptoms:

·      Explore: "Did you experience any headache, dizziness, or loss of consciousness?"

·      Headaches are less common with TIAs but can occur.

·     Medical and Social History:

·      Risk Factors: "Do you have a history of hypertension, diabetes, or heart disease?"

·      Lifestyle: "Do you smoke or consume alcohol regularly?"

·     Medication History:

·      Ask: "What medications are you currently taking?"

·      Particularly focus on anticoagulants and antiplatelet agents.

Examination Findings: What to Look For

During physical examination, focus on the following:

·     Neurological Examination:

·      Perform a thorough neurological assessment including:

·      Cranial Nerves: Check for any deficits.

·      Motor and Sensory Function: Assess for weakness or sensory loss, particularly in the face, arm, or leg on one side.

·      Speech: Evaluate for dysarthria or aphasia.

·      Coordination and Gait: Look for signs of ataxia or imbalance.

·     Cardiovascular Examination:

·      Examine for signs of heart disease:

·      Auscultate: Listen for abnormal heart sounds that may indicate arrhythmias.

·      Blood Pressure: Measure blood pressure to assess for hypertension.

·     Other Signs:

·      Assess for any signs of underlying conditions, such as:

·      Retinal Examination: Look for evidence of retinal emboli or signs of hypertension.

·      Carotid Bruit: Presence of a bruit might indicate carotid artery disease.

Investigations: What to Order

·     Immediate Imaging:

·      CT Head: Order a CT scan to rule out hemorrhagic stroke. A TIA might not show abnormalities on CT, but it's crucial for exclusion.

·      MRI Brain: If available, an MRI can be more sensitive in detecting ischemic changes.

·     Carotid Ultrasound:

·      Doppler Ultrasound: Assess for significant carotid artery stenosis, which can be a source of emboli.

·     Cardiac Evaluation:

·      ECG: Check for atrial fibrillation or other arrhythmias that could have contributed to the TIA.

·      Echocardiogram: Consider if there's suspicion of a cardiac source of emboli.

·     Blood Tests:

·      Full Blood Count, Electrolytes, Renal Function: Rule out other causes and assess general health.

·      Lipid Profile: Evaluate cholesterol levels to manage risk factors.

Management Plan: Immediate and Long-Term Care

·     Acute Management:

·      Antiplatelet Therapy: Initiate aspirin (300 mg daily) unless contraindicated. Clopidogrel (75 mg daily) may be considered in specific cases.

·      Control Risk Factors: Manage blood pressure, diabetes, and cholesterol levels aggressively.

·      Referral: Consider urgent referral to a stroke specialist or TIA clinic for further evaluation and management.

·     Long-Term Management:

·      Secondary Prevention: Based on risk factors and test results, prescribe antiplatelet therapy or anticoagulants if indicated (e.g., if atrial fibrillation is present).

·      Lifestyle Modifications: Advise on smoking cessation, alcohol moderation, and diet changes.

·      Regular Monitoring: Schedule follow-up appointments to monitor progress and adjust treatment as necessary.