Managing transient ischaemic attack in first 48 hrs: NICE 2019 Guidelines
The National Institute for Health and Care Excellence (NICE) has released its latest 2019 Guideline for the diagnosis and initial management of transient ischaemic attack in over 16s. This guideline covers interventions in the acute stage of transient ischaemic attack (TIA). It offers the best clinical advice on the diagnosis and acute management of TIA in the 48 hours after onset of symptoms.
Key Recommendations are :
1. Rapid recognition of symptoms and diagnosis
Prompt recognition of symptoms of stroke and transient ischaemic attack
- Use a validated tool, such as FAST (Face Arm Speech Test), outside hospital to screen people with sudden onset of neurological symptoms for a diagnosis of stroke or transient ischaemic attack (TIA). [2008]
- Exclude hypoglycaemia in people with sudden onset of neurological symptoms as the cause of these symptoms. [2008]
- For people who are admitted to the emergency department with a suspected stroke or TIA, establish the diagnosis rapidly using a validated tool, such as ROSIER (Recognition of Stroke in the Emergency Room). [2008]
Initial management of suspected and confirmed TIA
- Offer aspirin (300 mg daily), unless contraindicated, to people who have had a suspected TIA, to be started immediately. [2019]
- Refer immediately people who have had a suspected TIA for specialist assessment and investigation, to be seen within 24 hours of onset of symptoms. [2019]
- Do not use scoring systems, such as ABCD2, to assess risk of subsequent stroke or to inform urgency of referral for people who have had a suspected or confirmed TIA. [2019]
- Offer secondary prevention, in addition to aspirin, as soon as possible after the diagnosis of TIA is confirmed. [2008, amended 2019]
2. Imaging for people who have had a suspected TIA or acute non-disabling stroke
Suspected TIA
- Do not offer CT brain scanning to people with a suspected TIA unless there is clinical suspicion of an alternative diagnosis that CT could detect. [2019]
- After specialist assessment in the TIA clinic, consider MRI (including diffusion-weighted and blood-sensitive sequences) to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies. If MRI is done, perform it on the same day as the assessment. [2019]
Carotid imaging
- Everyone with TIA who after specialist assessment is considered as a candidate for carotid endarterectomy should have urgent carotid imaging. [2008, amended 2019]
Urgent carotid endarterectomy
- Ensure that people with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of 50 to 99% according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria:
- are assessed and referred urgently for carotid endarterectomy to service following current national standards
- receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice). [2008, amended 2019]
- Ensure that people with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less than 70% according to the European Carotid Surgery Trial (ECST) criteria:
- do not have surgery
- receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice). [2008]
- Ensure that carotid imaging reports clearly state which criteria (ECST or NASCET) were used when measuring the extent of carotid stenosis. [2008]
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