TIA Diagnostic Pathway
Key
Backing Information
Patient presents to GP or
A&E with Acute
Neurological symptoms
Primary Care
Secondary Care
To access the supporting
information, hold down Ctrl
and left click the
icon
1
Referral Template
Refer to TIA Team
Non-hemispheric
neurological event
2
3
Assessment of patient
4
Refer to
Neurovascular clinic
5
Completed Stroke
TIA
6
7
Assessment of patient
8
9
Invoke TIA
Treatment/ Prevention
10
Go to Stroke
pathway
Suspected TIA
11
Carotid Imaging
12
Positive
13
On call vascular
surgeon regional
network
15
Negative
14
Discharge patient
and make an
appointment for the
Neurovascular clinic
16
Operate on next list
17
Approval Date: 04/11/2010
Review Date: 04/11/2012
Page 1 of 6
Referral Templates
Click on the most appropriate referral template below:
Morriston & Singleton Hospitals TIA Template
Swansea TIA referral
form 100104_Word.doc
Neath Port Talbot Hospital TIA Template
TIA NPTH Referral
form_word Oct 2010.doc
Princess of Wales Hospital TIA Template
TIA POWH Referral
form_word Jan 2010.doc
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1. Patient presents to GP or A&E with Acute Neurological symptoms
The following events may be neurovascular and appropriate investigation will be undertaken
after consultant assessment.
 Loss of consciousness
 Acute confusion
 Inability to walk
 Vertigo
 Dizziness
 Memory loss
 Dizzy do
In the event that the patient presents on a Friday afternoon the Doctor (A&E/ Medical/GP) may
commence the following treatment in addition to referring to the TIA Team:
 Start aspirin 300mg as a loading dose, if not on any antiplatelet and then continue as 75mg
od+ Dipyridamole MR 200mg bd (consider adding a PPI if aspirin GI intolerant; use
Clopidogrel 300mg loading and 75mg maintenance if truly aspirin allergic)
 Add Dipyridamole MR 200mg bd if already on Aspirin
 Prescribe a Statin (simvastatin 40mg)
 Optimize BP control if systolic > 130mmhg by using existing medication or starting an ACE/
thiazide combination
 Advise lifestyle risk factors and smoking cessation
 Advise not to drive/ operate heavy machinery/ fly until seen in TIA clinic
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3.
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Non-hemispheric neurological event
Loss of consciousness
Acute confusion
Inability to walk
Vertigo
Dizziness
Memory loss
Dizzy do
These events may be neurovascular and appropriate investigation will be undertaken after
consultant assessment.
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Approval Date: 04/11/2010
Review Date: 04/11/2012
Page 2 of 6
4. Assessment of patient
Scope:
 this page describes initial assessment and diagnosis in hospital of ischaemic stroke, transient
ischaemic attack (TIA) or haemorrhagic stroke in adults
Out of scope:
 initial assessment and diagnosis:
 in children
 of subarachnoid haemorrhage
Stroke is a medical emergency and requires an immediate response.
Definition:
 TIA:
o rapid onset of global or focal impairment of brain function
o due to vascular pathology
o lasts less than 24 hours
 stroke:
o rapid onset of global or focal impairment of brain function
o due to vascular pathology
o lasts more than 24 hours or results in death
 ischaemic stroke:
o occurs in approximately 80% of people with stroke
o usually due to:
 in situ disease of small vessels due to hypertension and diabetes; or
 atherosclerotic plaque rupture and local vessel occlusion (usually in the carotid
artery); or
 thromboembolism usually from an atrial thrombus secondary to atrial
fibrillation
 haemorrhagic stroke:
o occurs approximately in approximately 20% of people with stroke
o it may be due to:
 in situ disease of small vessels due to hypertension; or
 atherosclerotic disease in the cerebral vessels (which weakens the vessel
walls); or
 cerebral amyloid angiopathy which is increasingly recognised in the elderly; or
 congenital aneurysms or arteriovenous malformation in the cerebral vessels
Incidence and prevalence:
 stroke – approximately 110,000 people per year have a first or recurrent stroke in England
 TIA – approximately 20,000 people per year in England
 stroke accounted for 11% of all deaths in the England and Wales in 1999
Risk factors:
 increasing age
 male gender
 Afro-Caribbean or Asian background
 Hypertension
 Diabetes
 atrial fibrillation
 previous history of stroke or ischaemic heart disease
 high cholesterol
 smoking
 carotid stenosis
 excessive alcohol consumption
Approval Date: 04/11/2010
Review Date: 04/11/2012
Page 3 of 6
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obesity
lack of exercise
a diet that is:
o high in saturated fats
o high in salt
o low in fresh fruit and vegetables
congenital heart disease
Clinical Assessment:
Use FAST (2):
 Facial Weakness
 Arm Weakness
 Speech Problem
 Test all three symptoms
Other possible associated symptoms/ signs:
 Amaurosis Fugax
 Ataxia (sudden onset)
 Homonymous Hemianopia
 Diplopia with other brainstem symptoms
Stratify Patient Risk:
Use referral form for result of ABCD2 scoring system for history and assessment: this stratifies
the patient's risk of stroke within the next 48 hours
ABCD2 score
48 hour stroke risk
4-7
4- 8 %
0-3
1%
Consider for acute admission if:
 Ongoing symptoms
 Crescendo TIA (more than 2 episodes of TIA in a week even if ABCD2 score is <3)
 New neuro symptoms while on warfarin
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6. Completed Stroke
Stroke
Sudden onset of neurological symptoms and/or signs lasting more than a few hours
Symptoms or signs ongoing (TIA or stroke not defined)
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7. TIA
TIA
 Amaurosis fugax
 Transient:
o Hemiparesis
o Monoparesis
o Facial droop
Approval Date: 04/11/2010
Review Date: 04/11/2012
Page 4 of 6
o
o
o
Expressive dysphasia
Acute dysarthria
Unilateral facial and/or limb sensory symptoms
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10. Invoke TIA Treatment/ Prevention
The following treatment is to be undertaken:
 Start aspirin 300mg as a loading dose, if not on any antiplatelet and then continue as 75mg
od+ Dipyridamole MR 200mg bd (consider adding a PPI if aspirin GI intolerant; use
Clopidogrel 300mg loading and 75mg maintenance if truly aspirin allergic)
 Add Dipyridamole MR 200mg bd if already on Aspirin
 Prescribe a Statin (simvastatin 40mg)
 Optimize BP control if systolic > 130mmhg by using existing medication or starting an ACE/
thiazide combination
 Advise lifestyle risk factors and smoking cessation
 Advise not to drive/ operate heavy machinery/ fly until seen in TIA
 Optimise glycaemic control
 Consider heart rhythm to exclude AF
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12. Carotid Imaging
Carotid endarterectomy
 should be considered if ultrasound demonstrates carotid stenosis greater than 50%, but not if
the carotid is almost occluded
 endarterectomy is not indicated in people with less than 30% stenosis and is probably not
beneficial in people with between 30-50% stenosis
 surgery should be performed within 2 weeks of stroke or transient ischaemic attack (TIA) if
patient is fit for surgery
 angioplasty may be an alternative, although its effectiveness is not yet proven and it is not
yet clear who should be considered for the procedure
 repeat Doppler ultrasound performed as close to surgery as possible (due to possible error)
 angioplasty or endarterectomy should be performed only in specialised centres where
appropriate expertise and resources are available
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References:
 Royal College of Physicians (RCP). National clinical guidelines for stroke second edition.
London: RCP; 2004.
 New Zealand Guidelines Group (NZGG). Life after stroke. New Zealand guideline for
management of stroke. Wellington: NZGG; 2003.
 Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke part
II: Management of carotid stenosis and carotid endarterectomy. Publication no. 14.
Edinburgh: SIGN; 1997.
 Hanley D, Gorelick PB, Elliott WJ et al. Determining the appropriateness of selected surgical
and medical management options in recurrent stroke prevention: A guideline for primary care
physicians from the National Stroke Association work group on recurrent stroke prevention. J
Stroke Cerebrovasc Dis 2004; 13: 196-207.
Approval Date: 04/11/2010
Review Date: 04/11/2012
Page 5 of 6
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Singapore Ministry of Health. Stroke and transient ischaemic attacks: Assessment,
investigation, immediate management and secondary prevention. Singapore: Ministry of
Health; 2003.
Veterans Health Administration, Department of Defense. VA/DoD Clinical practice guideline
for the management of stroke rehabilitation in the primary care setting. Washington, DC:
Department of Veteran Affairs; 2003.
Approval Date: 04/11/2010
Review Date: 04/11/2012
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