of
the arterial lumen. There is now consensus that it is important
to identify early, from among those patients presenting with
TIAs, those who may have a significant degree of carotid artery
stenosis by using colour Duplex ultrasonography.
To ensure that the full benefit is gained in a rapid and efficient
manner, an agreed protocol for "fast track" referrals
is essential and has been designed in agreement with the providing
hospital. General practitioners will need to be aware of the
system to exploit it fully.
1
European Carotid Surgery Trialists' Collaboration Group. MRC
European carotid surgery trial : interim results for symptomatic
patients with severe (70-99%) or with mild stenosis (0-29%)
carotid stenosis. Lancet 1991; 337 : 1235-43
2
North American Symptomatic Carotid Endarterectomy Trial Collaborators.
Beneficial effect of carotid endarterectomy in symptomastic
patients with high grade stenosis. Northern England Journal
of Medicine 1991; 325 : 445-53
Referral
Guidelines
All
patients who have had a carotid territory TIA should be referred
for investigation unless they have contraindications.
The
referral should, wherever possible, be made within two weeks
of the episode, to the TIA CLINIC.
The
service will offer colour Duplex scan and other necessary
diagnostic tests and, where appropriate, early surgical treatment
(or referral for surgical treatment). It is emphasised that
the primary purpose of the "fast track" scheme is
to select out rapidly those patients who might benefit from
early surgical intervention and manage other risk factors
of stroke.
Clinical
Guidelines for "Fast-Track" Referrals of TIAs
SYMPTOMS
Suitable
The following symptoms, if of less than 24 hours duration,
may suggest carotid territory TIA :
 |
Hemiparesis |
|
Hemianaesthesia |
|
Dysphasia |
|
Amaurosis
fugax |
|
Dyspraxia |
|
Spatial
disorientation |
Also
Suitable
The following symptoms are less suggestive of carotid territory
TIAs and more suggestive of vertebral territory TIAs :
|
Dizziness |
|
Vertigo |
|
Drop
attacks |
|
Confusion |
|
Diplopia |
|
Blackouts |
NOTES
Stroke with good functional recovery is also suitable for
"fast-track". Patients who respond to Aspirin are
still suitable for "fast-track".
A
Carotid Bruit is not important; those who do not have a bruit
should still be referred.
CONTRAINDICATIONS
ABSOLUTE
|
Cancer |
|
Complete
stroke with poor functional recovery |
|
Dementia |
|
Patient
unwilling to consider surgery under any circumstances |
RELATIVE
Age is a relative contraindication but fit patients over the
age of 75 should not be excluded.
Myocardial
infarction in the last six months or unstable angina in the
last six months are both relative contraindications to surgery
within this period, but should still be referred.
Patients
who have had a minor stroke (symptoms persisting for >24
hours) with rapid and complete/near complete neurological
recovery are suitable for the fast-track system. Patients
who have had a complete stroke with poor neurological recovery
are not suitable for the fast-track system, but should be
referred for secondary prevention ( i.e. of recurrent stroke).
Patients in this group whom general practitioners think might
benefit from surgery should be referred to a physician on
an individual basis.
MEDICAL
TREATMENT
All patients with TIA should be considered for medical treatment,
which includes:
Correction
of risk factors: smoking, hyperlipidaemia
Treatment of Hypertension (to achieve systolic BP of <140
mmHg)
Anti-platelet therapy (Aspirin 75 mg od), anticoagulation
with Warfarin for those in atrial fibrillation, and based
on more recent evidence (results of PROGRESS research),
consideration for combination therapy with Perindopril 4mg
od and Indapamide 2.5mg od for secondary prevention in selected
patients.
CLINICIAN
OFFERING A FAST-TRACK SERVICE AT NORTH MANCHESTER GENERAL
HOSPITAL
DR
U AHMED, Consultant Physician
Telephone 0161 720 2790
FAX 0161 720 2613
SERVICES
FOR PATIENTS WITH TIA AT NORTH MANCHESTER GENERAL HOSPITAL
TIA
CLINIC
REFERRAL
PATHWAY
|
