TIA and Carotid Disease — Written Clinical Reasoning

SAQ 1 — Urgent TIA plan (12 marks)

Prompt: Outline your immediate assessment and management plan, including antithrombotic strategy and imaging priorities. Justify with evidence. ^{[2] [5] [9]}

Case vignette: A 71-year-old man with 20 minutes of right face-arm weakness and dysphasia, now fully resolved, presenting 3 hours after onset. No known AF. ^[9]

Model Answer

1. Frame as high-risk cerebral ischaemia, not a resolved benign spell (3 marks) ^[9]

This is a high-risk TIA phenotype: cortical features (dysphasia, face-arm weakness) fully resolved. Tissue-based definition means MRI may still show infarction, but the prevention pathway is urgent either way. ^{[9] [6]}

2. System of care (3 marks) ^[5]

Use an EXPRESS-style urgent pathway: same-day specialist assessment and immediate secondary prevention rather than delayed outpatient review. Early recurrent stroke risk is front-loaded and modifiable by rapid care. ^{[5] [1]}

3. Antithrombotic therapy (3 marks) ^{[2] [3]}

Assuming non-cardioembolic mechanism pending work-up, start short dual antiplatelet therapy (aspirin + clopidogrel) aligned with CHANCE/POINT, then step down after a short course. Do not continue dual therapy long term without a specific indication. If AF is found, switch strategy toward anticoagulation. ^{[2] [3] [7]}

4. Imaging and mechanism chase (3 marks) ^{[6] [8]}

Urgent brain imaging as indicated, urgent extracranial carotid imaging (duplex/CTA/MRA), ECG plus rhythm monitoring, labs, and risk-factor bloods. Symptomatic high-grade carotid stenosis needs timely revascularisation discussion. ^{[6] [8]}