C. Aspirin 300mg immediately + specialist review within 24 hours – Explanation
This patients age, blood pressure and duration of symptoms would put her in a higher risk category.
Current guidelines advocate specialist review within 24 hours
Transient ischaemic attack
NICE issued updated guidelines relating to stroke and transient ischaemic attack (TIA) in 2008. They
advocated the use of the ABCD2 prognostic score for risk stratifying patients who’ve had a
suspected TIA:
| Criteria | Points | |
| A | Age >= 60 years | 1 |
| B | Blood pressure >= 140/90 mmHg | 1 |
| C | Clinical features – Unilateral weakness – Speech disturbance, no weakness |
2 1 |
| D | Duration of symptoms – > 60 minutes – 10-59 minutes |
2 1 |
| Patient has diabetes | 1 |
This gives a total score ranging from 0 to 7. People who have had a suspected TIA who are at a
higher risk of stroke (that is, with an ABCD2 score of 4 or above) should have:
- aspirin (300 mg daily) started immediately
- specialist assessment and investigation within 24 hours of onset of symptoms
- measures for secondary prevention introduced as soon as the diagnosis is confirmed, including
discussion of individual risk factors
If the ABCD2 risk score is 3 or below:
- specialist assessment within 1 week of symptom onset, including decision on brain imaging
- if vascular territory or pathology is uncertain, refer for brain imaging
People with crescendo TIAs (two or more episodes in a week) should be treated as being at high
risk of stroke, even though they may have an ABCD2 score of 3 or below.
NICE also published a technology appraisal in 2010 on the use of clopidogrel and dipyridamole
Recommendations from NICE include:
- aspirin plus modified-release (MR) dipyridamole is still recommended as first choice for people who
have had a TIA, but now there is no recommended limit on the duration of treatment. Clopidogrel is
not recommended
- MR dipyridamole monotherapy is recommended after TIA only if aspirin is contraindicated or not
tolerated, again with no limit on duration of treatment.
With regards to carotid artery endarterectomy:
- recommend if patient has suffered stroke or TIA in the carotid territory and are not severely
disabled - should only be considered if carotid stenosis > 70% according ECST* criteria or > 50% according
to NASCET** criteria
*European Carotid Surgery Trialists’ Collaborative Group
**North American Symptomatic Carotid Endarterectomy Trial
