Tia (transient ischaemic attack) protocol

TIA (Transient Ischaemic Attack) Protocol
Use only if symptoms < 24 hrs and completely resolved.
If brain imaging shows haemorrhage, use Main Stroke Protocol.
For supporting information e.g. images & documents, refer to web site at: http://nbsvr73/medicine/StrokeService/StrokeProtocol.html Seek specialist advice for all patients
In patients presenting within 1 week of symptom onset
STRATIFY RISK OF STROKE AFTER TIA
Use ABCD2 score (see box below & web site)
Risk is highest in the first 24 hours: Nearly half of strokes occurring ≤ 30 days from TIA
occur within 24 hrs.
High risk patients need to be seen within 24 hours of symptom onset
If high risk patients cannot be seen in TIA clinic within 24 hours, admit to ward 106
High risk patients include:
- Crescendo TIAs or >1 TIA in 1 week- ABCD2 score 4 or more (see Box).
ABCD2 SCORE
or
or
ANTI-PLATELETS and ANTICOAGULATION
Atrial fibrillation
Atrial Fibrillation
Warfarin should generally be used to treat atrial Annual risk of stroke without
fibrillation in all patients with TIA without treatment (see web site)
contraindications to anticoagulation.
In patients on, or potentially eligible for warfarin: - Rule out intracerebral haemorrhage (ICH) - Once ICH excluded, warfarin can be initiated Estimated average annual risk of
- Give aspirin 75 mg od and clopidogrel 75 mg od recurrent stroke +/- treatment
until INR therapeutic (and for at least 5 days) In patients in whom warfarin is contraindicated: - In patients presenting < 48 hours from symptom onset, give aspirin 300 mg + clopidogrel 300 mg single dose immediately, followed byaspirin 75 mg od and clopidogrel 75 mg od indefinitely.
- In patients presenting 48 hours or more from symptom onset omit loading doses of aspirin and clopidogrel, and give aspirin 75 mg od and clopidogrel 75 mg od indefinitely.
No atrial fibrillation
Patient presenting < 48 hours from symptom onset or high risk (e.g. ABCD4, see above):
Aspirin 300 mg + clopidogrel 300 mg single dose immediately, then aspirin 75 mg od +
clopidogrel 75 mg od for 1 month, then Asasantin one tablet twice daily for 2 years, then
aspirin 75 mg daily.
If patient presents outside 48 hours and lower risk: Aspirin 300 mg for remainder of first 2 weeks from onset, then Asasantin as above for 2 years followed by aspirin 75 mg daily.
Use clopidogrel 75 mg od monotherapy in place of Asasantin if tablets need crushing e.g. dysphagia (in preference to immediate release dipyridamole).
Use clopidogrel 75 mg od in place of aspirin or Asasantin if either drug not tolerated INVESTIGATIONS
Carotid imaging (inpatient / urgent outpatient) All carotid imaging investigations are specialised, and should be • Carotid dopplers first line, but should be arranged only with the TIA service.
• CT angio. carotids. Seek specialist advice. Useful if dopplers non-diagnostic or suggest carotid occlusion or stenosis close to cut-off for surgery (50-70% stenosis).
Note risk of contrast nephropathy.
• MR angiography. Seek specialist advice. Used for above indications if CT angio contraindicated, or for patients undergoing MRI for other reasons.
Echocardiography (usual y outpatient) Consider if:• Cardioembolic source possible & cardiac murmur / abnormal cardiac silhouetteCardiac rhythm monitoring (outpatient)• 24 hour tape (or 48 hour tape) if AF suspected.
• Consider event recorder if palpitationsNeuroimaging (inpatient / urgent outpatient)MRI with DWI is the primary brain imaging modality for the diagnosis of TIA.
Also consider imaging if:• Warfarin being considered (plain CT)• Other cause for symptoms suspected (e.g. tumour)• Dissection suspected (MRA / CTA) CHOLESTEROL LOWERING TREATMENT
Cholesterol lowering drugs: Simvastatin 40 mg od if chol.  3.6 and not on statin (or
on pravastatin). If on treatment & cholesterol  3.6, increase according to cholesterol lowering effect: Simvastatin 40 mg  Atorvastatin 40 mg  Rosuvastatin 10 mg. Add other agents if required.
BLOOD PRESSURE LOWERING TREATMENT
Treat if BP  110 systolic and no symptoms of postural hypotension.
Start perindopril 2 mg od; 7 days later increase to 4 mg; 7 days later add indapamideMR 1.5 mg od. Subsequent increases if hypertensive. Monitor U&Es.
DRIVING, LIFESTYLE, AND OTHER ADVICE
• No driving for 1 month, or 3 months and contact DVLA if >1 event in 1 month.
(see http://www.dft.gov.uk/dvla/medical/ataglance.aspx) Patients may resume driving after this time if clinical recovery is complete.
• Patients must notify DVLA if focal neurological deficit after 1 month (note these patients by definition have stroke not TIA).
• Vocational license / Group 2 (e.g. HGV) drivers should contact DVLA and not drive for Refer to TIA clinic
if not admitted.
• Lifestyle advice: Smoking cessation, diet, exercise, alcohol Acute stroke unit. Frenchay Ward 106, ext 03106 / 03934Stroke rehab unit. Southmead Ward 1, ext 35064 Jane Wroath. Tue - Fri bleep 9325. Or message via ext 35064 Dr Neil Baldwin, sec Frenchay ext 06636, sec Southmead ext 35368 Useful web sites:
Stroke information and patient support: Stroke Association: www.stroke.org.ukBristol Area Stroke Foundation: www.stroke-bristol.org/ National Clinical Guideline for Stroke: http://bookshop.rcplondon.ac.uk/details.aspx?e=250NICE acute stroke and TIA guidelines: http://guidance.nice.org.uk/CG68

Source: http://www.severn-pathology.com/sites/default/files/filedepot/incoming/TIA%20(Transient%20Ischaemic%20Attack)%20Protocol%20-%20Use%20only%20if%20symptoms%2024%20hrs%20and%20completely%20resolved.pdf