TIA The calm before the storm

Aims TIA – what it is and what it’s not Assessment and investigations Management Discuss risk factors Secondary stroke prevention

Stroke Definition A transient ischemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours. In addition visual symptoms such as sudden onset of monocular visual loss should be included. (The National Institute of Clinical Excellence 2008 (NICE) ASA – Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without evidence of acute infarction

Incidence 35 people out of every 100,000 each year have a TIA. 10–20% of those who have had a TIA will go on to have a stroke within a month & the greatest risk is within the first 48 hours.

Diagnostic challenges Event occurred in the past, often not witnessed -30% delay seeking medical attention for >24 hours Reliant on patient’s history -Pt may be unable to completely recall symptoms -May use vague descriptions “dizziness”,“confused heaviness” Clinical examination usually normal Many causes of transient neurology (50% of pts referred to TIA clinic) No diagnostic test

Non focal symptoms Faintness Light headedness General weakness Confusion Syncope Non specific dizziness

Transient Focal Neurology TIA epilepsy Migraine aura (+/- headache) Transient Global Amnesia Multiple sclerosis Intracranial structural lesion Metabolic disturbance Many more

Transient monocular blindness (Amaurosis Fugax) Sudden loss of vision in the whole or part of the visual field of one eye. Lasts seconds-minutes Retinal ischeamia Atherothromboembolism from ICA or cardiac embolism Can be other cause of TMB eg glaucoma, Central or branch retinal vein thrombosis Glaucoma Retinal haemorrhage

Case study 1 At the gym, drove home According to wife –”confused”, repeatedly asking “What day is it? No limb or facial weakness Symptoms resolved after 4 hours Pt has no recollection of event Is this a TIA

Transient Global Amnesia Temporary, isolated disorder of memory Impaired ability to form new memory Asks pertinent questions repeatedly Symptoms last < 24 hours Unable to recall episode once recovered Precise pathophysiology unclear

Transient Global Amnesia 3/100,000 cases per annum More common in males Precipitants – physical exertion, cold water exposure, overwhelming emotional stress, pain Annual recurrence rate 3% No increased risk of stroke

Case Study 2 – 27 year old male Sudden onset numbness and weakness in (L) hand Resolved within 1 hour No past medical history IS THIS A TIA

Right hemispheric TIA

TIA – what's the urgency? Stroke, MI, death 5% stroke within 2 days Common Serious recurrent vascular events Stroke, MI, death Most occur in first few days 5% stroke within 2 days 11% stroke within 1 week

ABCD2 Age > 60yrs = 1 point Blood pressure >140/90 = 1 point Clinical features – Diabetes = 1point Unilateral weakness = 2 points Speech disturbance = 1point Duration of symptoms > 60min = 2 points 59 mins = 1 point – Diabetes = 1 point

Risk stratification ABCD2 Score 2 day risk 7 day risk 0-3 1.0% 1.2% 4-5 4.1% 5.9% 6-7 8.1% 11.7% Johnston, Rothwell et al. Lancet 2007;369:283-292

Risk Factors for Stroke Non- Modifiable Older age Male sex Ethnicity Genetic Predisposition Modifiable (Major) Socioeconomic Class Obesity Physical Inactivity Smoking Alcohol Hypertension Previous Stroke/TIA Atherosclerosis Atrial Fibrillation Structural cardiac abnormalities Diabetes Modifiable (Minor) Diet Recreational Drug Use Sleep disordered breathing Thrombophilia Inflammation & Infection Migraine HRT Table 1 – Risk Factors for Stroke. Markus et al, 2010

Risk Factors for Stroke Non-modifiable Risk Factors Helps identify those at greatest risk Thereby enabling active treatment of those risk factors that can be modified in these patients

Non-Modifiable risk factors Age – most powerful independent risk factor Gender – male higher risk Family history - increased risk if a first-degree relative has had coronary heart disease or stroke before the age of 55 years (for a male relative) or 65 years (for a female relative). Ethic group Older Age - Strongest risk factor for ischaemic stroke and primary intracerebral haemorrhage The incidence of stroke doubles with every decade after the age of fifty five More than three-quarters of strokes occur in the people aged over sixty five Men have a slightly greater risk of stroke (especially under the age of 75)

Modifiable risk factors High blood pressure Being over weight Excessive alcohol Smoking Poor diet High cholesterol Lack of physical activity

Atrial Fibrillation AF is the most common cause of cardio embolic stroke Risk of stroke in people with AF is 5-6X greater than those in sinus rhythm Paroxysmal AF has the same stroke risk as persistent AF and therefore should be treated the same

Secondary prevention Active management of modifiable risk factors Carotid endarectomy Pharmacological - concordance and compliance Life style advice given to all (including information on driving & sex) Blood pressure target Cholesterol target 1

Stroke secondary prevention trials Progress (BP lowering trial with ACE) Match (aspirin + clop) Caprie (clop v aspirin) Sparcl (atorvastatin) Blood Pressure Lowering Treatment Trialists’ Collaboration Cochrane reviews

Medication in practice Anti platelet / anticoagulant - Clopidogrel, Warfarin, NOAC Statin – Atorvastatin, Anti hypertensive treatment –ACE , Life long (NICE 2008 RCP 2012) Statins improve endothelial function Plague stabilization Anti inflammatory properties Anti thrombitic properties

PCCS TIA Service Follow on support to TIA Patient's diagnosed by NUH fast track service Offered full health assessment, symptom and medication advise. Support with lifestyle changes to reduce risk of TIA/Stroke Access to phase 3 exercise programme Access to cardiac team OT and councillor Refer through SPAR