Non-Covid clinical crises: TIA
Pulse’s series on how to manage non-Covid subacute problems when you’re out of your comfort zone and there’s minimal help available
When you receive a call from a patient or more likely from their spouse or carer with a short history of an acute neurological deficit of some form which developed suddenly or within minutes and resolved completely within 24 hours, do consider transient ischaemic attack as the most likely cause.
TIA is relatively common condition affecting around 20,000 patients a year in UK. It can affect anyone at any age it is more common in men over the age of 55 years who are overweight and smokers. Other main risk factors include hypertension, diabetes mellitus, underlying ischaemic heart disease and atrial fibrillation.
Patients usually present with a sudden, localised deficit affecting face, arm, or speech (remember the FAST acronym), vision (causing diplopia or amaurosis fugax), or vestibular system (causing vertigo).
Sudden continuous vertigo that is affecting a patient’s balance and equilibrium is likely to be vascular in origin unless it is short-lived and brought on or made worse by head movements. Rarely TIA can present with acute delirium, however transient loss of consciousness, seizures or transient amnesia are unlikely to be secondary to vascular events.
When called, remember to check for hypoglycaemia as it can mimic TIA, in those who are diabetics on oral hypoglycaemic medications or insulin. Ask the patient to take Aspirin 300mg straight away unless they are anticoagulated for AF for example and even if they are on Aspirin or Clopidogrel 75mg.
Instruct them to call 999 if patient is still symptomatic to be admitted to manage a possible stroke. If already recovered reassure them, consider continuing them on the Aspirin 300mg daily and refer them for an assessment at the TIA/Stroke service according to your local referral pathway.
I suggest you arrange a follow up virtual consultation with your patient following their assessment at the clinic to ensure full understanding of the diagnosis and the importance of the long term management to prevent further strokes.
Although they do not need to inform the DVLA unless holding bus or lorry licence, patients must not drive for a month following an event.
Based on their frailty index, you might like to start the discussion about advanced care planning including end of life care and resuscitation.
- TIA is an acute neurological deficit that resolves within 24 hours
- Exclude hypoglycaemia in treated diabetics
- Give Aspirin 300mg stat
- If still symptomatic ask them to call 999 for hospital admission
- If resolved continue on Aspirin 300mg a day and refer urgently to the local TIA/Stroke service
- Consider follow up for further management including psycho-social assessment and advanced care planning
Dr Nassif Mansour is a GPwER in neurology and chair of the Primary Care and Community Neurology Society