Transient Ischaemic Attack

Pathway

Images

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1a		Left Common and Internal Carotid Artery Stenosis Image 1a and 1b (Carotid Doppler): Moderate amount of plaque at the origin of the left common carotid artery (arrow) extending into the internal carotid artery. Velocity measurements indicate stenosis in the order of 70%.
1b
2		Left Middle Cerebral Artery Stenosis Image 2 (MR Angiography): Narrowing of the left middle cerebral artery with reduced flow (arrow).
3a		Left Internal Carotid Artery Stenosis Image 3a and 3b (Digital Subtraction Angiography): Pre- and post-angioplasty views of a left internal carotid artery stenosis (arrows).
3b

Teaching Points

Teaching Points

• Patients with TIA should preferably undergo neuroimaging evaluation within 24 hours of symptoms onset
• A non-contrast computed tomography (CT) is the initial imaging modality of choice in suspected TIA to identify haemorrhage, ischaemia or space occupying lesion
• Carotid Doppler ultrasound should be performed to assess for extracranial arterial stenosis or plaque
• If the carotid arteries are normal (i.e. no plaque) or had <70% stenosis, alternative sources of cerebral emboli should be considered (Echocardiogram/Holter)
• After carotid Doppler, Magnetic Resonance Imaging (MRI)-Brain and Magnetic Resonance Angiography (MRA)-Head and Neck should be considered to assess for ischaemic changes in brain parenchyma and carotid artery stenosis with plaque characteristics respectively
• If there is uncertainty as to the degree of carotid stenosis, further non-invasive imaging with CT Angiography is recommended. If two noninvasive tests are discordant, Cerebral Catheter Angiogram should be considered
• Treatment options include medical management, carotid endarterectomy or carotid angioplasty/stenting for athero-occlusive disease of the carotid artery

References

References

Date of literature search: May 2016

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

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18. Chappell FM, Wardlaw JM, Young GR, Gillard JH, Roditi GH, Yip B, et al. Carotid artery stenosis: accuracy of noninvasive tests-individual patient data meta-analysis. Radiology. 2009;251(2):493-502. (Level I Evidence). View the reference
19. Remonda L, Senn P, Barth A, Arnold M, Lovblad KO, Schroth G. Contrast-enhanced 3D MR angiography of the carotid artery: comparison with conventional digital subtraction angiography. AJNR American journal of neuroradiology. 2002;23(2):213-9. (Level II Evidence). View the reference
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Further Reading

1. Barnett HJM, Meldrum HE, Eliasziw M, for the North American Symptomatic Carotid Endarterectomy Trial (NASCET) collaborators. The appropriate use of carotid endarterectomy. CMAJ. 2002;166(9):1169-79. (Review article)
2. CAVATAS investigators Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. 2001;357:1729-37. (Level II evidence)
3. Barnett HJM, Taylor DW, Eliasziw M, et al, for the North American Symptomatic Carotid Endarterectomy Trial Collaborators. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med. 1998;339:1415-25

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