Phys Written Answers · neurological
TIA and Carotid Disease — Written Clinical Reasoning
DCE-style written reasoning for high-risk TIA: urgent pathway, dual antiplatelet therapy, carotid imaging and revascularisation thresholds.
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Target exams
SAQ 1 — Urgent TIA plan (12 marks)
Prompt: Outline your immediate assessment and management plan, including antithrombotic strategy and imaging priorities. Justify with evidence. [2] [5] [9]
Model Answer
1. Frame as high-risk cerebral ischaemia, not a resolved benign spell (3 marks) [9]
This is a high-risk TIA phenotype: cortical features (dysphasia, face-arm weakness) fully resolved. Tissue-based definition means MRI may still show infarction, but the prevention pathway is urgent either way. [9] [6]
2. System of care (3 marks) [5]
Use an EXPRESS-style urgent pathway: same-day specialist assessment and immediate secondary prevention rather than delayed outpatient review. Early recurrent stroke risk is front-loaded and modifiable by rapid care. [5] [1]
3. Antithrombotic therapy (3 marks) [2] [3]
Assuming non-cardioembolic mechanism pending work-up, start short dual antiplatelet therapy (aspirin + clopidogrel) aligned with CHANCE/POINT, then step down after a short course. Do not continue dual therapy long term without a specific indication. If AF is found, switch strategy toward anticoagulation. [2] [3] [7]
4. Imaging and mechanism chase (3 marks) [6] [8]
Urgent brain imaging as indicated, urgent extracranial carotid imaging (duplex/CTA/MRA), ECG plus rhythm monitoring, labs, and risk-factor bloods. Symptomatic high-grade carotid stenosis needs timely revascularisation discussion. [6] [8]
SAQ 2 — Carotid decision (8 marks)
Prompt: CTA shows 80% stenosis of the right internal carotid artery. Symptoms were left face-arm weakness and dysphasia. What next? [8] [4]
Model Answer
Confirm the stenosis is ipsilateral to the symptomatic hemisphere (here, left hemisphere symptoms imply left carotid disease — so re-check laterality before operating). If truly symptomatic high-grade stenosis, refer urgently for CEA/CAS discussion, continue intensive medical therapy, and avoid delay. NASCET supports endarterectomy benefit in high-grade symptomatic stenosis with acceptable operative risk; CREST informs stenting versus endarterectomy trade-offs. [8] [4] [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