Transient Ischaemic Attack (TIA) Management - Primary Care and Emergency Departments

Introduction

The diagnosis of a TIA is based entirely on a careful history, supplemented by a reliable eyewitness account if possible. A TIA is an acute FOCAL neurological deficit with loss of function, of sudden onset, such as: 

• Limb weakness or sensory change resulting in hemiplegia or hemisensory loss
• Speech disturbance, resulting in dysphasia or dysarthria
• Visual disturbance, e.g. amaurosis fugax, monocular scotoma with confirmed retinal artery occlusion, hemianopia or quadrantanopia.

The patient will typically have a clear recollection of the event and be able to describe it clearly. Impairment of consciousness or confusion does not occur. Not all symptoms need necessarily be present. Most attacks last under an hour, and usually last less than 15 minutes. 

Focal deficit lasting longer than an hour should be considered as a stroke and admitted to hospital (refer to the Acute Stroke and TIA Management - Inpatient guideline). 

Consider underlying cardiovascular causes (i.e. hypotension or cardiac arrhythmias) in patients presenting with transient symptoms of dizziness. Patients presenting with symptoms of acute vertigo and associated cerebellar signs would be more suggestive of a posterior circulation stroke, and should be admitted for investigation. 

There are, however, a range of diagnoses to be considered for transient focal neurological symptoms. In atypical presentations, it is appropriate to refer these patients to the Neurology or Neurovascular clinic for diagnosis and management.

See algorithm below, which outlines the TIA referral process and management of patients presenting with focal symptoms.

General management and drug therapy

Stroke diagnosis tool

• ROSIER (Recognition Of Stroke In the Emergency Room) Score: The ROSIER score, although primarily designed for stroke diagnosis, may also be useful in TIA diagnosis. The ROSIER helps distinguish genuine stroke from stroke mimics, such as hypoglycaemia, epilepsy or syncope. 

For the management of suspected stroke or TIA in primary care or ED, including the referral process, see below.

• PathwayManagement of suspected stroke or TIA in primary care or ED

N.B. The full guideline (link only active if accessing via NHS network) is available via AthenA / Guidelines - Prescribing / Cardiovascular.