Transient Ischemic Attack (TIA) Diagnostic Pathway

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1 Key Primary Care Secondary Care Transient Ischemic Attack (TIA) Diagnostic Pathway Patient presents to GP or A&E with Acute Neurological symptoms Click on the hyperlinks in the pathway to access the supporting information 1 2 Refer to TIA Team Non-hemispheric neurological event 3 4 Assessment of patient Refer to Neurovascular clinic 5 6 Completed Stroke 7 TIA Assessment of patient 8 9 Go to Stroke pathway Invoke TIA Treatment/ Prevention Suspected TIA Carotid Imaging 12 Positive Negative On call vascular surgeon regional network 15 Discharge patient and make an appointment for the Neurovascular clinic 16 Operate on next list 17 Page 1 of 5

2 1. Patient presents to GP or A&E with Acute Neurological symptoms The following events may be neurovascular and appropriate investigation will be undertaken after consultant assessment. Acute confusion Inability to walk Vertigo Dizziness Acute memory loss In the event that the patient presents on a Friday afternoon the Doctor (A&E/ Medical/GP) may commence the following treatment in addition to referring to the TIA Team: Prescribe aspirin or clopidogrel (depending on availability) 300mg stat and continue as clopidogrel 75mg od long term1 If intolerant or allergic to clopidogrel prescribe aspirin 75mg od plus modified release dipyridamole 200mg bd If both clopidogrel and dipyridamole are contraindicated or not tolerated use aspirin 75mg od (consider adding a PPI if aspirin GI intolerant). If both clopidogrel and aspirin are contraindicated or not tolerated use modified release dipyridamole 200mg bd.# The combination of aspirin and clopidogrel is not recommended for log term prevention after TIA or stroke unless there is another indication such as acute coronary syndrome or recent coronary stent procedure. Prescribe a Statin (simvastatin 40mg) Optimize BP control if systolic > 130mmhg by using existing medication or starting an ACE/ thiazide combination Advise lifestyle risk factors and smoking cessation Advise not to drive/ operate heavy machinery/ fly until seen in TIA Optimise glycaemic control Consider heart rhythm to exclude AF For patients in atrial fibrillation, paroxysmal or permanent, anticoagulation should be considered urgently. Eligible patients should have brain imaging (CT) before initiating anticoagulation 3. Non-hemispheric neurological event Acute confusion Inability to walk Vertigo Dizziness Acute memory loss These events may be neurovascular and appropriate investigation will be undertaken after consultant assessment. 4. Assessment of patient Scope: this page describes initial assessment and diagnosis in hospital of ischaemic stroke, transient ischaemic attack (TIA) or haemorrhagic stroke in adults Out of scope: initial assessment and diagnosis: in children of subarachnoid haemorrhage Stroke is a medical emergency and requires an immediate response. Page 2 of 5

3 Definition: TIA: o rapid onset of global or focal impairment of brain function o due to vascular pathology o lasts less than 24 hours, most less than an hour stroke: o rapid onset of global or focal impairment of brain function o due to vascular pathology o lasts more than 24 hours or results in death ischaemic stroke: o occurs in approximately 80% of people with stroke o usually due to: in situ disease of small vessels due to hypertension and diabetes; or atherosclerotic plaque rupture and local vessel occlusion (usually in the carotid artery); or thromboembolism usually from an atrial thrombus secondary to atrial fibrillation haemorrhagic stroke: o occurs approximately in approximately 20% of people with stroke o it may be due to: in situ disease of small vessels due to hypertension; or atherosclerotic disease in the cerebral vessels (which weakens the vessel walls); or cerebral amyloid angiopathy which is increasingly recognised in the elderly; or congenital aneurysms or arteriovenous malformation in the cerebral vessels Incidence and prevalence: stroke approximately 110,000 people per year have a first or recurrent stroke in England TIA approximately 20,000 people per year in England stroke accounted for 11% of all deaths in the England and Wales in 1999 Risk factors: increasing age male gender Afro-Caribbean or Asian background Hypertension Diabetes atrial fibrillation previous history of stroke or ischaemic heart disease high cholesterol smoking carotid stenosis excessive alcohol consumption obesity lack of exercise a diet that is: o high in saturated fats o high in salt o low in fresh fruit and vegetables congenital heart disease Clinical Assessment: Use FAST (2): Facial Weakness Arm Weakness Speech Problem Test all three symptoms Page 3 of 5

4 Other possible associated symptoms/ signs: Amaurosis Fugax Ataxia (sudden onset) Homonymous Hemianopia Diplopia with other brainstem symptoms Stratify Patient Risk: Use referral form for result of ABCD2 scoring system for history and assessment: this stratifies the patient's risk of stroke within the next 48 hours ABCD2 score 48 hour stroke risk % 0-3 1% Consider for acute admission (urgent (same day) assessment) if: Ongoing symptoms Crescendo TIA (more than 2 episodes of TIA in a week even if ABCD2 score is <3) New neuro symptoms while on antiplatelet or anticoagulant therapy 6. Completed Stroke Stroke Sudden onset of neurological symptoms and/or signs lasting more than a few hours Symptoms or signs ongoing (TIA or stroke not defined) 7. TIA TIA Amaurosis fugax Transient: o Hemiparesis o Monoparesis o Facial droop o Expressive dysphasia o Acute dysarthria o Unilateral facial and/or limb sensory symptoms 10. Invoke TIA Treatment/ Prevention The following treatment is to be undertaken: Prescribe aspirin or clopidogrel (depending on availability) 300mg stat and continue as clopidogrel 75mg od long term1 If intolerant or allergic to clopidogrel prescribe aspirin 75mg od plus modified release dipyridamole 200mg bd If both clopidogrel and dipyridamole are contraindicated or not tolerated use aspirin 75mg od (consider adding a PPI if aspirin GI intolerant). If both clopidogrel and aspirin are contraindicated or not tolerated use modified release dipyridamole 200mg bd.# The combination of aspirin and clopidogrel is not recommended for log term prevention after TIA or stroke unless there is another indication such as acute coronary syndrome or recent coronary stent procedure. Prescribe a Statin (simvastatin 40mg) Page 4 of 5

5 Optimize BP control if systolic > 130mmhg by using existing medication or starting an ACE/ thiazide combination Advise lifestyle risk factors and smoking cessation Advise not to drive/ operate heavy machinery/ fly until seen in TIA Optimise glycaemic control Consider heart rhythm to exclude AF For patients in atrial fibrillation, paroxysmal or permanent, anticoagulation should be considered urgently. Eligible patients should have brain imaging (CT) before initiating anticoagulation 12. Carotid Imaging Carotid endarterectomy should be considered if ultrasound demonstrates carotid stenosis greater than 50%, but not if the carotid is occluded endarterectomy is not indicated in people with less than 30% stenosis and is probably not beneficial in people with between 30-50% stenosis surgery should be performed within 2 weeks of stroke or transient ischaemic attack (TIA) if patient is fit for surgery angioplasty may be an alternative, although its effectiveness is not yet proven and it is not yet clear who should be considered for the procedure repeat Doppler ultrasound performed as close to surgery as possible (due to possible error) angioplasty or endarterectomy should be performed only in specialised centres where appropriate expertise and resources are available References: Royal College of Physicians (RCP). National clinical guidelines for stroke second edition. London: RCP; New Zealand Guidelines Group (NZGG). Life after stroke. New Zealand guideline for management of stroke. Wellington: NZGG; Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke part II: Management of carotid stenosis and carotid endarterectomy. Publication no. 14. Edinburgh: SIGN; Hanley D, Gorelick PB, Elliott WJ et al. Determining the appropriateness of selected surgical and medical management options in recurrent stroke prevention: A guideline for primary care physicians from the National Stroke Association work group on recurrent stroke prevention. J Stroke Cerebrovasc Dis 2004; 13: Singapore Ministry of Health. Stroke and transient ischaemic attacks: Assessment, investigation, immediate management and secondary prevention. Singapore: Ministry of Health; Veterans Health Administration, Department of Defense. VA/DoD Clinical practice guideline for the management of stroke rehabilitation in the primary care setting. Washington, DC: Department of Veteran Affairs; Page 5 of 5

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