Background

Assessment

1. Typical symptoms of TIA
   • Unilateral weakness
   • Unilateral altered sensation
   • Dysphasia
   • Monocular blindness
   • Hemiamopia
2. Symptoms not typical of TIA
   • Confusion (exclude dysphasia)
   • Impaired consciousness or syncope
   • Dizziness or light headedness
   • Generalized weakness or sensory symptoms
   • Bilateral blurred vision or scintillating scotoma
   • Incontinence: bladder or bowel
   • Amnesia
3. Other Symptoms
   • Ataxia, vertigo, dysphagia, dysarthria, and sensory symptoms to part of one limb or the face may be consistent with TIA if they occur in conjunction with other typical symptoms.
   • NB: Transient loss of consciousness ('blackout') without focal neurological symptoms or signs is NOT a TIA.
4. FAST Screening Test
   • FACE - ask the patient to smile. Is there a facial droop on one side?
   • ARM - ask the patient to raise both arms to 90 degrees. Is there a weakness on one side?
   • SPEECH - is there a new speech disturbance eg slurring, word-finding difficulties or difficulty naming objects?
   • TIME - if the patient has any of these signs at the time of assessment, get to hospital FAST. They may be eligible for thrombolysis. Early intervention in stroke makes a difference.
5. The FAST screening test looks for signs of stroke in the carotid (anterior) circulation. Remember that posterior circulation strokes also need to be admitted to hospital.
6. Table outlining the clinical features of TIA/stroke with arterial territory

   Anterior (carotid) circulation	Posterior (vertebrobasilar) circulation
   Cortical dysfunction (ie dysphasia, sensory or visual inattention, hemianopia) Monocular blindness Unilateral weakness Unilateral sensory disturbance Dysarthria* Neuromuscular dysphagia*	Cranial nerve palsy Ataxia/inco-ordination Diplopia Isolated homonymous hemianopia Bilateral visual loss Unilateral/bilateral weakness Unilateral/bilateral sensory disturbance Dysarthria* Neuromuscular dysphagia*

   *Less likely to be TIA/stroke if symptoms in isolation.

Management

1. If the patient still has symptoms or signs of stroke at the time of assessment, they need to be admitted to hospital immediately. The patient may need urgent thrombolysis or other intervention. Phone stroke physician or medical team on duty.
2. This pathway recognises that some patients present late. If a patient has probably had a stroke and presents after 2 weeks or more, they can be referred to the TIA Clinic instead (in the absence of any other reason for admission).
3. Assess Risk
   • Is the ABCD2 score 4 or more?

     ABCD2 SCORE for TIA:

     Score
     Age	> 60	1
     Blood pressure	>140/90	1
     Clinical features	Unilateral weakness Speech disturbance alone Other	2 1 0
     Duration of symptoms	> 60 minutes 10-59 minutes < 10 minutes	2 1 0
     Diabetes	Present	1

   • Is the patient in AF?
   • Has the patient had more than one TIA in the last week?
   • Is the patient anti-coagulated?
4. If YES to any one of these questions treat as high risk and admit to hospital
   • In WBOP phone stroke registrar on 027 268 8658 Mon-Fri 8am-4pm, or on-call medical registrar after hours, at Tauranga Hospital.
   • In EBOP phone on-call physician at Whakatane Hospital.
5. If NO to all four risk questions, treat as low risk:
   • In WBOP, refer to TIA Service at Tauranga Hospital. Complete e-referral on BPAC, and inform patient that they may receive a phone call from the hospital stroke specialist.
   • In EBOP, discuss with on-call physician at Whakatane Hospital.
6. For all low risk patients
   • Optimise BP control (<140/80, in diabetes <130/80)
   • Lipid control (40-80mg OD atorvastatin)
   • Lifestyle advice (weight, diet etc)
   • Antiplatelets
     1. 1st line treatment: clopidogrel 75mg OD
     2. 2nd line treatment: if unable to tolerate clopidogrel give low dose aspirin with dipyridamole modified release 150mg BD
     3. 3rd line treatment if unable to tolerate dipyridamole then aspirin low dose monotherapy

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.