Recent Developments in the Diagnosis and Management of Patients with Transient Ischaemic Attacks and Minor Ischaemic Strokes

Abstract

Appropriate management of the patient with transient focal neurological symptoms must start with accurate clinical diagnosis. Wider use of clear diagnostic criteria and symptom checklists, and better knowledge of the clinical features of the 'funny turns' which are not related to transient focal cerebral ischaemia could reduce the present variability in clinical diagnosis of transient ischaemic attacks. More accurate clinical diagnosis contributes to better selection of the most appropriate investigation strategy for each patient. A basic minimum standard of investigation is outlined and perhaps provides a suitable template for audit. Patients with transient ischaemic attacks which are definitely in the carotid distribution may be eligible for entry in trials of carotid endarterectomy. Prudent use of duplex ultrasound studies of the carotid arteries in patients with appropriate symptoms is an effective way to reduce the costs of investigations and their complications (i.e. the number of strokes associated with cerebral angiography). Digital venous subtraction angiography has, by comparison, many disadvantages as a screening tool. Advances in management include: recent statistical overviews which have emphasized the need to consider blood pressure and plasma cholesterol reduction in a large proportion of patients, and the value of long term anti-platelet therapy in reducing the risks of stroke, myocardial infarction and vascular death in both males and females. The value of anticoagulants in patients with atrial fibrillation and transient ischaemic attacks or minor stroke is being tested in current trials.