Phys Clinical Cases · neurological
TIA and Carotid Disease — DCE Clinical Case
DCE long-case/short-case station for high-risk TIA: urgent pathway, dual antiplatelet therapy, carotid imaging and secondary prevention counselling.
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TIA and Carotid Disease — Clinical Case
DCE Long Case
Patient brief
Patient: Mr Alan Wright, 71 years old. [6]
Presenting complaint: At 08:00 he developed sudden right-face droop, right-arm weakness and difficulty finding words lasting 20 minutes, fully resolved by 08:30. He presents at 11:00 feeling back to normal but frightened. [9]
Past history:
- Type 2 diabetes
- Hypertension
- Hyperlipidaemia
- Ex-smoker (restarted recently)
- No known AF [7]
Medications: Metformin, perindopril, atorvastatin (intermittent adherence). No antiplatelet currently. [7]
Examination: BP 168/92, HR 78 regular, neurologically normal, soft left carotid bruit, no murmurs. [6]
Investigations so far: Non-contrast CT brain — no haemorrhage. ECG sinus. Capillary glucose 9.1. [6]
Tasks
- Present a problem list and urgent management plan. [5]
- Explain antithrombotic choices and duration. [2] [3]
- Outline carotid imaging and revascularisation thresholds. [8]
Model discussion points
Problem list: high-risk TIA (cortical features); uncontrolled vascular risk factors; possible symptomatic carotid disease; medication non-adherence; driving and safety counselling needs. [1] [7]
Plan: urgent stroke/TIA pathway; short DAPT if non-cardioembolic; same-day/urgent carotid imaging; rhythm monitoring; high-intensity statin and BP plan; smoking cessation; educate on recurrence symptoms. [2] [5] [7]
If ipsilateral 70–99% stenosis: urgent CEA/CAS referral plus continued medical therapy. [8] [4]
Short case
Counsel a patient on why a resolved deficit still needs urgent prevention, using plain language and checking understanding. [5] [7]
References
- [1]Johnston SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack Lancet, 2007.PMID 17258668
- [2]Wang Y, Wang Y, Zhao X, Liu L, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack N Engl J Med, 2013.PMID 23803136
- [3]Johnston SC, Easton JD, Farrant M, Barsan W, et al. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA N Engl J Med, 2018.PMID 29766750
- [4]Brott TG, Hobson RW 2nd, Howard G, Roubin GS, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis N Engl J Med, 2010.PMID 20505173
- [5]Rothwell PM, Giles MF, Chandratheva A, Marquardt L, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison Lancet, 2007.PMID 17928046
- [6]Fonseca AC, Merwick Á, Dennis M, Ferrari J, et al. European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack Eur Stroke J, 2021.PMID 34414306
- [7]Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association Stroke, 2021.PMID 34024117
- [8]North American Symptomatic Carotid Endarterectomy Trial Collaborators, Barnett HJM, Taylor DW, Haynes RB, et al. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis N Engl J Med, 1991.PMID 1852179
- [9]Easton JD, Saver JL, Albers GW, Alberts MJ, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists Stroke, 2009.PMID 19423857