Stroke- TIA
a4medicine.co.uk/stroke-tia
August 14, 2017
. Presentations which can mimic TIA or Stroke are described with a focus on recognition
and use of assessment tools as FAST and ROSIER ( several other tools also exist ).
Management of TIA based on the ABCD risk scoring is shown in greater detail. The reader
is advised to consider discussing DVLA guidance and complications of stroke are
mentioned ( encountered frequently ). The charity stroke association can be a useful tool
in advising patients in a post stroke scenario.
Stroke-Clinical syndrome consisting of rapidly developing clinical signs of focal ( at times
global ) disturbance of cerebral function lasting more than 24 hrs or leading to death with
no apparent cause other than that of vascular origin
TIA-Acute loss of focal cerebral or ocular function with symptoms lasting less than 24 hrs
and which is thought to be due to inadequate cerebral or ocular blood supply as a result of
low blood flow , thrombosis or embolism associated with diseases of the blood vessel ,
heart or blood ( Hankey and Warlow 1994 )Tissue based definition ( event lasting less
than 1 hour without cerebral infarction ) on MRI brain scan requires early scanning and is
thus limited in generalisabilityTIA is associated with a very high risk of stroke in the first
month after the event and upto 1 year afterwards
Major health problem in UK Most people survive a first stroke but often have significant
morbidity In England estimated cost to economy is around £8 billion / year This burden
will increase as population demographics change Over 80,000 people in England and
Wales are admitted with acute stroke each year Use of term CVA should be abandoned as
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it implies that the stroke is a chance event for which little can be done Brain attack – an
alternative term used to describe the acute presentation of stroke and TIA ( it removes the
requirement for a delay of 24 hrs to diagnose stroke )
Risk factors-Smoking Alcohol and drug abuse Physical inactivity poor diet.Hypertension
Permanent and Paroxysmal AF estimated that AF causes more than 20 % of ischaemic
strokes Infective endocarditis Valvular disease Carotid artery disease Congestive cardiac
failure Congenital or structural heart disease including patent foramen ovale Age Gender
Men ↑ likely to suffer with stroke at younger ageWomen ↑ risk with COCP use , migraine
with aura , immediate post-partum period and pre-eclampsia Hyperlipidaemia Diabetes
mellitus Sickle cell disease Antiphospholipid syndrome and other hypercoagulable
disorders CKD Obstructive sleep apnoeaindependent risk factor +usually associated with
other comorbidities
Presentation with sudden onset and cannot be explained by another condition such as
hypoglycaemia Unilateral weakness or sensory loss Dysphasia Ataxia , vertigo or in-
coordination Syncope Amaurosis fugax- sudden transient loss of vision in one eye
Homonympus hemianopia Cranial nerve defectsTIA may only last minutes and symptoms
often resolve before patient is seen. Collateral history is important. R/O TIA
Mimics Migraine aura Seizure Syncope Functional or anxiety related Vestibular disorders
Metabolic eg hypoglycaemia Delirium eg sepsis Suspected TIA- all patients who have
ongoing symptoms however mild are considered to have had stroke and urgent transfer to
hospital should be arranged Confusion , altered level of consciousness and coma
Headache – sudden severe and unusual headache which may be associated with neck
stiffnessSentinel headache(s) may occur in the preceding weeks Weakness – sudden loss
of strength in the face or limbs Sensory loss- paraesthesia or numbness Speech problems
as dysarthria Visual problems – visual loss or diplopia Dizziness ,vertigo or loss of balance
isolated dizziness usually not a symptom of TIA Nausea and / or vomiting Cranial nerve
deficits as○ unilateral tongue weakness○ Horner’s syndrome – miosis , ptosis and facial
anhidrosis Difficulty withfine motor co-ordinationgait Neck facial pain ( arterial
dissection ) Post circulation stroke – acute vestibular syndrome○ acute persistent ,
continuous vertigo or dizziness with nystagmus , nausea or vomiting○ head motion
intolerance and○ new gait unsteadiness
ABCD2 score-Age – 60 yrs and older ( 1 point ) Blood pressure Systolic >= 140 ( 1 point )
Diastolic >= 90 ( i point )Clinical features Any unilateral weakness ( 2 points ) Speech
impairment without weakness ( 1 point )Duration60 minutes or more (2 points )10-59
minutes ( 1 point )Diabetes mellitis ( 1 point )
Suspected stroke-Confusion , altered level of consciousness and coma Headache – sudden
severe and unusual headache which may be associated with neck stiffnessSentinel
headache(s) may occur in the preceding weeks Weakness – sudden loss of strength in the
face or limbs Sensory loss- paraesthesia or numbness Speech problems as dysarthria
Visual problems – visual loss or diplopia Dizziness ,vertigo or loss of balanceisolated
dizziness usually not a symptom of TIA Nausea and / or vomiting Cranial nerve deficits as
○ unilateral tongue weakness○ Horner’s syndrome – miosis , ptosis and facial anhidrosis
Difficulty withfine motor co-ordinationgait Neck facial pain ( arterial dissection ) Post
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circulation stroke – acute vestibular syndrome○ acute persistent , continuous vertigo or
dizziness with nystagmus , nausea or vomiting○ head motion intolerance and○ new gait
unsteadiness Mimics-Seizure Sepsis Toxic/ metabolic Space occupying lesion Syncope
Delirium Vestibular Mononeuropathy Functional Dementia Migraine Spinal cord lesions
Other
FAST test- Facial asymmetry- 1 pt Arm weakness 1 pt Speech disturbance – 1 pt Time
Some people with stroke with not be identified by FAST test eg○ sudden onset visual
disturbance○ lateralising cerebral dysfunction Continue to treat as having a suspected
stroke if suspected despite a negative FAST test-Emergency hospital admission to stroke
unit Explain to the ambulance staff about situation Inform the hospital in advance Do not
start antiplatelet treatment until haemorrhagic stroke has been r/o While awaiting
transfer○ monitor ABC○ give oxygen if saturation < 95 % and no CIs If not admitted ( not
beneficial / appropriate )○ document clearly○ discuss with specialist team and possible
assessment and management at home or as Outpatient within 24 hrs
Complications of stroke-Early period following stroke○ haemorrhagic transformation of
ischaemic stroke○ cerebral oedema○ seizures○ VTE – PE in 13 – 25 % of deaths ○ cardiac
problems MI , CCF , AF and arrthymias○ Infection – aspiration pneumonia , UTI and
cellulitis from pressure sores Long term○ Mobility problemsHemiparesis or hemiplegia (
affects about 80 % of people with stroke )Ataxia -lack of co-ordinated movementFalls
Spasticity and contractures○ Sensory problems- altered sensation as touch , temp and
pain○ Continence problems Urinary and fecal incontinence is common following stroke○
Pain○ Fatigue○ Swallowing hydration nutrition problems swallowing impairment
common○ Sexual dysfunction○ Skin problems – pressure sores○ Visual problems -altered
acuity , hemianopia , diplopia , nystagmus and blurred vision○ Cognitive problems○
Emotional and psychological problems○ Communication problems○ Difficulties with
activities of daily living○ Loss of income
References
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the acute phase BMJ 2011 ; 342 :d 1938
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Management Guideline and Protocol Advisory Committee
https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-
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14. More than half the stroke patients were not given preventative drugs , study finds
BMJ 2016 ; 355 :i6105
15. Royal College of Physicians National clinical guideline for stroke Prepared by the
Intercollegiate Stroke Working Party Fifth Edition 2016
16. https://www.strokeassociation.org/idc/groups/stroke-
public/@wcm/@hcm/documents/downloadable/ucm_309713.pdf
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Transient ischaemic attacks: mimics and chameleons
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tools
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