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A 72-year-old man with type 2 diabetes, hypertension and a 40-pack-year smoking history presents to the emergency department after a 30-minute episode of sudden right-sided arm and face weakness with slurred speech that has now fully resolved. His wife witnessed the onset one hour ago. On examination he is neurologically intact; his first blood pressure is 168/96 mmHg, pulse is irregularly irregular at 92/min, and a left carotid bruit is audible. Capillary glucose is 6.4 mmol/L. CT brain shows no haemorrhage or infarct.
Questions
a) What is the most likely diagnosis and what is his ABCD2 score? (2 marks)
Diagnosis: Transient ischaemic attack (TIA) in the left (dominant) anterior circulation (right face/arm weakness + dysphasia), with atrial fibrillation and left carotid stenosis as likely mechanisms.
ABCD2 = 6 (HIGH risk): Age over 60 (1) + BP over 140/90 (1) + unilateral weakness (2) + duration 10 to 59 min (1) + diabetes (1) = 6. This predicts a two-day stroke risk of around 8 percent.
b) Outline the urgent investigations you would arrange. (3 marks)
- CT brain (already done) excludes haemorrhage; MRI with diffusion-weighted imaging (DWI) if available to confirm/exclude infarction (tissue-based definition).
- Carotid imaging within 24 h — duplex Doppler first-line (left carotid bruit); CTA/MRA if stenosis confirmed or to plan surgery.
- 12-lead ECG (irregular pulse suggests atrial fibrillation); confirm AF and consider echocardiography and prolonged monitoring (Holter/loop) for paroxysmal AF.
- Bloods — glucose, fasting lipids, FBC, U&E, coagulation, HbA1c.
c) Describe the immediate and secondary-prevention management. (3 marks)
- Specialist assessment within 24 h (admit given ABCD2 over 4, AF and recurrent-event risk).
- Antiplatelet is NOT the priority here once AF is confirmed — anticoagulation with a DOAC is indicated for cardioembolic prevention (start after imaging excludes haemorrhage; TIA itself carries no haemorrhagic-transformation delay unlike completed stroke).
- If carotid duplex shows symptomatic stenosis over 70 percent (NASCET), arrange carotid endarterectomy within 2 weeks (NNT 3 for over 70 percent).
- Vascular risk-factor control: high-intensity statin (LDL reduction over 50 percent), BP target under 130/80 once stable, glycaemic control, smoking cessation.
d) What are the two most important prognostic risks over the next 90 days, and how much can urgent treatment reduce them? (2 marks)
- Completed stroke — without treatment approximately 10 to 20 percent within 90 days (5 to 10 percent within 48 h).
- Long-term cardiovascular mortality (reduced life expectancy, mostly from MI/vascular disease).
Urgent specialist assessment plus aggressive secondary prevention can reduce the 90-day stroke risk by up to 80 percent (EXPRESS / SOS-TEL evidence).