THE TIA SERVICE AT KINGS
COLLEGE HOSPITAL
Gloria Ekeng
Clinical Nurse Specialist for Stroke & TIA
Kings College Hospital
WHAT IS A TIA?
A
Transient Ischaemic Attack (TIA) is the
term used for stroke symptoms that fully
resolve within 24 hrs with no residual
deficit.
 It
is an important warning of a more
serious stroke.
 Time
window for effective treatment
among high risk groups is very short.
KEY SYMPTOMS OF A TIA ARE
 Weakness
 Numbness
 clumsiness
or pins and needles on one
side of the body, for example in an arm,
leg or the face
 loss of or blurred vision in one or both
eyes
 slurred speech or difficulty finding some
words
TIA FACTS

35 people out of every 100,000 each year have a
TIA

10-20% of those who have had a TIA will go on to
have a stroke within a month.

The greatest risk is within the first 72 hours

The risk of a recurrent stroke is 30-43% within 5
years
PREDICTION OF STROKE RISK
In a population based study, the risk of stroke
after a first TIA was 8.6% at 7 days and 12% at
30 days.
 In an Emergency Department (ED) based study
in Northern California, the 90 day risk of stroke
after a TIA was 10.5% but half of these strokes
occurred very early within the first 2 days of the
TIA
 Even more recently it has been shown that 42%
of the strokes which occur in the 30 days after a
TIA actually occur within the first 24 hours
highlighting the need to treat TIAs as an acute
medical emergency.

WHY BOTHER?....
Stroke is preventable.
TIA: very high risk factor for a stroke – with greatest
risk within 48 – 72 hours. Therefore patients must be
seen, assessed & treated rapidly! (very high risk pts
within 24hours by specialist team)
Cost to the NHS health economy (NAO Report) 2005

£2.8 billion direct care costs

£1.8 billion due to lost productivity & disability

£2.4 billion informal care costs

2.6 million bed days / year
USING ABCD2 SCORE
The ABCD2 Score has been shown to be
predictive of the risk of stroke at 2 days after a
TIA
 A score is assigned according to the patient’s Age,
Blood pressure, Clinical features, Duration of
symptoms and Diabetes (Table 1)


For patients with an ABCD score of 0-3, the 2 day
risk of stroke after a TIA was 1%, for those with a
score of 4-5, the 2 day risk was 4.1% and for those
with a score of 6-7 the risk was 8.1%
TABLE 1
PREDICTION OF STROKE RISK
There are certain circumstances, however, where
the ABCD Score does not quite reflect the
patient’s true risk.
 The National Clinical Guideline for Stroke state
very clearly that people with crescendo TIAs (two
or more TIAs in a week) should be treated as
being at high risk of stroke and treated as an
emergency even though they may have an ABCD2
score of 3 or below

COMMON TIA MIMICS
Migraine
 Partial seizure
 Ocular disorders
 Hypoglycaemia
 Vestibular disorders
 Brain tumour
 Subdural haematoma
 Arteritis
 Hyperventilation
 Primary cerebral amyloid

CASE STUDY
A 64 year man presented to his GP following a 30
minute episode of speech disturbance and rightsided weakness; by the time he reached the GP’s
surgery, he had returned to normal and no
neurological deficits were noted.
MRI of the brain, carotid doppler's and ECG were
performed that same day, according to the TIA
Protocol. The conventional sequences of the MRI
appeared normal, but the Diffusion Weighted
Image MRI showed a minute area of infarction
(Figure 1).
(FIGURE 1).
Very
small
area of
infarctio
n in
L MCA
territory
THE TIA SERVICE AT KINGS
The TIA service at Kings College Hospital is a
fast-track service in which all patients with
suspected TIA are seen, investigated and treated
within 24 hours of referral, 7 days a week
 All suspected High Risk TIA patients are
immediately admitted for observation and workup.
 Low Risk patients are seen within 24 hours of
receipt of the referral.
 If high grade carotid stenosis is identified, the
patient is seen by the vascular surgeons on the
same day and booked for early carotid
endaterectomy, usually within 48 hours.

HOW TO REFER TO THE TIA SERVICE.
High risk patients i.e.
 ABCD2 score of 4 or more
 Recurrent TIAs
 Pts in AF or on Warfarin
Pts with prominent head and neck pain suggesting
dissection should be sent to the Emergency
Department (A&E) 24 hours a day, 7 days a
week, for same day investigation and admission.
HOW TO REFER TO THE TIA
SERVICE.
Low risk suspected TIAs with a score of 0-3 should
be referred immediately to the TIA service:
Monday to Friday by contacting the TIA Nurse
specialist on 07528977503 or the SpR on call for
stroke via KCH switchboard 020 3299 9000, or by
Fax No: 020 3299 8504. On weekends or out of
hours, please contact the SpR on call for stroke
via switchboard as the TIA nurse is not available
and the Fax is not manned.
REFERENCES



Easton JD, Saver JL, Albers GW, 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.
Stroke 2009; 40:2276-93.
Lovett JK, Dennis MS, Sandercock PAG, Bamford J,
Warlow CP, Rothwell PM. Very early risk of stroke after a
first transient ischaemic attack. Stroke 2003; 34:138-140.
Johnston SC, Gress DR, Browner WS, Sidney S. Short term
prognosis after emergency department diagnosis of TIA.
JAMA 2000; 284(22): 2901-2906.
REFERENCES



Chandratheva A, Mehta Z, Geraghty OC, Marquardt
L, Rothwell PM On behalf of the Oxford Vascular
Study. Population-based study of risk and predictors
of stroke in the first few hours after a TIA.Neurology
2009; 72: 1941-1947.
Johnston SC, Rothwell PM, Nguyen-Huynh MN,
Giles MF,Elkins JS, Bernstein AL, Sidney S.
Validation and refinement of scores to predict very
early stroke risk after transient ischaemic attack.
Lancet 2007; 369: 283-292.
Royal College of Physicians Intercollegiate Stroke
Working Party. National clinical guidelines for stroke.
3rd Edition, 2007. P47.