Initial management of suspected transient cerebral ischaemia and stroke in primary care: implications of recent research

Abstract

Strategies are required to reduce the personal, societal and healthcare burden caused by cerebrovascular disease. Urgent medical intervention after transient ischaemic attack (TIA) can prevent recurrent stroke, and modern healthcare has to respond rapidly to the patient with TIA. The primary care practitioner contributes to stroke prevention by rapidly and accurately diagnosing TIA and arranging urgent specialist assessment. Diagnosis of TIA in primary care is difficult, as transient symptoms are common. Stroke-screening tools are available, but there is no evidence base for diagnostic support tools for TIA in primary care. The ABCD2 scoring system identifies patients after TIA at high early risk, and secondary care assessment within 24 h is reserved for patients with a high predicted risk. General practitioners are advised to give aspirin at the time of diagnosis, although prescribing a full range of vascular risk-reducing therapies may be appropriate. Specialist assessment confirms the diagnosis, usually with cerebral imaging (preferably MRI to detect cerebral injury), and carotid ultrasound will detect patients suitable for endarterectomy. Patients with suspected stroke should be urgently transferred to the nearest stroke centre, for assessment and investigation before potential thrombolysis, which may be effective within a longer timeframe than current practice. Primary care follow-up is essential to ensure adherence to evidence-based therapies. Dual combinations of antiplatelet agents (aspirin and dipyridamole) and antihypertensive agents (ACE inhibitors and thiazides) as well as high-dose statins have proven benefit. For patients in atrial fibrillation, even if very elderly, anticoagulation has a net benefit in preventing stroke.