TIA and Carotid Disease Viva

Long Case Viva Defence

Candidate opening statement

"Mr Jones is a 71-year-old man with diabetes, hypertension and smoking who had twenty minutes of left face and arm weakness with dysphasia that fully resolved. He is now neurologically normal. This is a high-risk TIA phenotype until proven otherwise. My priorities are urgent specialised assessment, immediate secondary prevention including short dual antiplatelet therapy if non-cardioembolic, urgent carotid and cardiac rhythm evaluation, and time-sensitive revascularisation if he has symptomatic high-grade carotid stenosis." ^{[1] [4] [8]}

Examiner questions

Q1: "Symptoms resolved. Why not send him home with GP follow-up next month?" ^[4]

"Because early stroke risk is front-loaded and EXPRESS showed that urgent assessment with immediate treatment reduces early recurrent stroke compared with delayed care." ^{[4] [5]}

Q2: "What is the modern definition of TIA?" ^[8]

"A transient episode of focal neurological dysfunction due to ischaemia without acute infarction on a tissue-based definition, rather than a pure 24-hour time cut-off." ^[8]

Q3: "Justify dual antiplatelet therapy." ^[1]

"CHANCE and POINT showed early aspirin plus clopidogrel reduces early recurrence after high-risk TIA or minor non-cardioembolic stroke. The benefit is early; prolonging dual therapy increases bleeding." ^{[1] [2]}

Q4: "When do you refer for carotid surgery?" ^[7]

"Recent symptomatic high-grade ipsilateral extracranial stenosis with acceptable perioperative risk — NASCET established benefit for endarterectomy; CREST informs stenting versus endarterectomy selection." ^{[7] [3]}

Q5: "He has a carotid bruit on the other side. So what?" ^[6]

"A bruit is neither sensitive nor specific. Management follows imaging-confirmed symptomatic disease and risk factors, not the bruit alone." ^[6]