Phys Vivas · neurological
TIA and Carotid Disease — Viva Defence
DCE viva for high-risk TIA and symptomatic carotid stenosis: definition, urgent pathway, DAPT, and revascularisation.
On this page & tools
Target exams
TIA and Carotid Disease Viva
Long Case Viva Defence
Candidate opening statement
"Mr Jones is a 71-year-old man with diabetes, hypertension and smoking who had twenty minutes of left face and arm weakness with dysphasia that fully resolved. He is now neurologically normal. This is a high-risk TIA phenotype until proven otherwise. My priorities are urgent specialised assessment, immediate secondary prevention including short dual antiplatelet therapy if non-cardioembolic, urgent carotid and cardiac rhythm evaluation, and time-sensitive revascularisation if he has symptomatic high-grade carotid stenosis." [1] [4] [8]
Examiner questions
Q1: "Symptoms resolved. Why not send him home with GP follow-up next month?" [4]
"Because early stroke risk is front-loaded and EXPRESS showed that urgent assessment with immediate treatment reduces early recurrent stroke compared with delayed care." [4] [5]
Q2: "What is the modern definition of TIA?" [8]
"A transient episode of focal neurological dysfunction due to ischaemia without acute infarction on a tissue-based definition, rather than a pure 24-hour time cut-off." [8]
Q3: "Justify dual antiplatelet therapy." [1]
"CHANCE and POINT showed early aspirin plus clopidogrel reduces early recurrence after high-risk TIA or minor non-cardioembolic stroke. The benefit is early; prolonging dual therapy increases bleeding." [1] [2]
Q4: "When do you refer for carotid surgery?" [7]
"Recent symptomatic high-grade ipsilateral extracranial stenosis with acceptable perioperative risk — NASCET established benefit for endarterectomy; CREST informs stenting versus endarterectomy selection." [7] [3]
Q5: "He has a carotid bruit on the other side. So what?" [6]
"A bruit is neither sensitive nor specific. Management follows imaging-confirmed symptomatic disease and risk factors, not the bruit alone." [6]
Short case
Discuss counselling after high-risk TIA: warning symptoms, medication adherence, smoking cessation, and local driving rules. [6]
References
- [1]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
- [2]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
- [3]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
- [4]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
- [5]Luengo-Fernandez R, Gray AM, Rothwell PM Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison Lancet Neurol, 2009.PMID 19200786
- [6]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
- [7]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
- [8]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