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Time taken to seek and receive
medical attention after TIA
T
ransient ischaemic attack (TIA)
is a brief episode of neurological
dysfunction resulting from focal
cerebral ischaemia not associated
with permanent cerebral infarction (Albers et
al, 2002). It is a warning sign that a stroke may
occur unless preventive steps are taken. By
definition, a TIA causes transient symptoms
only so has no long-term consequences per
se. However, an estimated 20% of strokes are
preceded by a TIA (Romthwell, 2005; Giles
et al, 2006).
Patients who experience a TIA have a high
risk of stroke within the 3 months of the
TIA occurring, ranging from 9% to 20% at
90 days (Kleindorfer et al, 2005). The risk
of stroke is particularly high in the first few
days following a TIA, which underlines the
need for urgent evaluation and treatment
(Nakajima et al, 2010).
The exact incidence of TIA is unknown. This
is because many people who have a TIA do
not report it to their doctor, as the symptoms
are temporary and their importance is not
recognised. It is estimated, however, that a TIA
occurs in about 35 per 100 000 people each
year in the UK (Castledine and Close, 2009).
Patients can also experience transient
focal neurological symptoms that are not
recommendation is the more widespread use
of validated tools, such as the ABCD2 score
and FAST tool, by GPs and A&E doctors, for
the prehospital diagnosis of stroke and TIA in
the UK (Royal College of Physicians, 2008).
The Department of Healths national stroke
strategy (DH, 2007) set out quality markers
and clinical guidelines to improve stroke and
TIA services. Healthcare for London (HfL,
2008), under the direction of the DH, set
performance indicators setting out how soon
people should receive medical attention,
depending on their risk.
The ABCD2 (age, blood pressure, clinical
features, duration and diabetes scoring system)
(Table 1) is a prognostic system based on
clinical data. It is designed to predict stroke
risk within 7 days after TIA to guide triage to
specialist care, target secondary prevention and
inform public education (Johnston et al, 2007).
The National Institute for Health and Clinical
Excellence (NICE, 2008) recommends
that the ABCD2 scoring system is used to
determine risk.
The ABCD2 score gives an approximate
prediction of risk at 2 days following the
first TIA, based on the features shown in
Table1. A score of 03 gives a risk of further
stroke in the next 2 days as 1%, 45 a risk
of 4% and 67 a risk of 8% (Rothwell et al,
2005). NICE (2008) defines patients with an
ABCD2 score of 4 or above as being at high
risk of stroke and recommends that these
patients should be seen in a specialist clinic
within 24 hours. People with an ABCD2
Elmer J Catangui
attributable to a focal cerebral ischaemia
(Dennis et al, 1989). Their conditions may
imitate TIAs and are labelled TIA mimics, in
the same way as conditions that imitate stroke
have been labelled stroke mimics (Winkler et
al, 2009). The percentage of TIA symptoms
that are caused by TIA mimics ranges from
10% to 48.5% (Quinn et al, 2009), depending
on the setting.
Prompt assessment and investigation of
TIA followed by early initiation of secondary
prevention is effective in reducing recurrent
stroke (Sprigg et al, 2009). Patients with
transient neurological symptoms may
underestimate their significance and delay
seeking specialist care or may wait days to
see a GP (Royal College of Physicians, 2008).
There is evidence that GPs continue to
delay the referral of patients with suspected
stroke or TIA to secondary or tertiary care
(National Audit Office, 2005). Accurate
and rapid assessment is critical. A priority
Abstract
A transient ischaemic attack (TIA) is a warning sign that a debilitating stroke
could occur unless preventive action is taken. People with suspected TIAs should
be seen urgently in a specialist service that provides rapid assessment, preventive
care and treatment. This article highlights the importance of seeking medical
attention urgently for suspected TIAs. It examines how quickly a specialist TIA clinic
investigates and treats TIAs. It also identifies factors that affect how quickly patients
with TIAs seek medical attention.
Key words: Transient ischaemic attack Acute stroke unit Stroke Stroke nurse
Elmer J Catangui is Clinical Nurse Specialist in
Stroke/TIA, Imperial College Healthcare NHS Trust
Accepted for publication: April 2013
Table 1. ABCD2 score
Symbol Clinical feature Criterion Point
A Age 60 1
B Blood pressure 140/90 mmHg 1
C Clinical features of the TIA Unilateral weakness 2
Speech disturbance without weakness 1
D1 Duration of symptoms 60 min 2
1059 min 1
<10 min 0
D2 Diabetes Diagnosis of diabetes 1
Source: Johnston et al, 2007
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score of 3 or less have a lower risk of stroke.
NICE (2008) recommends that they should
be seen in a specialist clinic within 7 days.
However, people with crescendo TIA (two
or more TIAs in a week) should be treated
as being at high risk of TIA, even though
they may have an ABCD2 score of three or
below. People who have had a TIA but who
present late (more than 1 week after their
last symptom has resolved) should be treated
using the low-risk pathway.
HfLs performance indicators state that 90%
of TIA patients should be seen by a specialist
service with 24 hours if they are at high risk or
within 7 days if at low risk (HfL, 2008). Despite
national guidelines and a campaign to increase
public awareness of stroke symptoms, many
patients are slow to seek medical advice after
TIA and health professionals do not act quickly.
This article provides a critical analysis of
how quickly people with suspected TIAs
contact health professionals from the time
of their symptoms onset. It also asks how
promptly health professionals refer these
patients to specialist clinics. In addition, it
shows how quickly a specialist TIA clinic
sees patients. It also identifies the reasons why
patients delay seeking medical attention after
experiencing TIAs.
Method
Prospective data was collected from January
2012 to October 2012 to identify timings of
the following:
Date of symptoms onset
Date of presentation to health professionals
Average number of days between symptoms
onset and presentation to health professionals
Number of high-risk TIAs seen within
24 hours based on (ABCD2) stratification
Number of low-risk TIAs seen within 7 days
based on the ABCD2 stratification
Number of stroke patients identified by the
TIA clinic
Number of stroke patients directly admitted
to the hyper-acute stroke unit from the TIA
clinic.
The stroke nurse specialist entered the
information to the protected database to
ensure and maintain confidential handling
and storage.
Results
From January 2012 to October 2012,
472 patients with suspected TIAs were seen
in the rapid access TIA clinic (Figure 1). Of
these, 226 (47%) had a probable TIA, 216
(48%) had TIA mimics and 30 (6%) had
confirmed diagnosis of a stroke. Of those who
had had a stroke, only 10 (33%) were admitted
to the hyper-acute stroke unit for further
management and treatment.
Of the 226 with a probable TIA diagnosis,
122 (54%) were high risk and 104 (46%) were
low risk (Figure 2).
Of the 122 high-risk patients, 51 (41.8%)
were seen on the same day they were referred
by a health professional (GP and or accident
and emergency (A&E) doctor) and 115
(94.2%) were seen within 24 hours. Only
six patients (5.8%) were not seen within 24
hours (Figure 3).
Of the 104 low-risk patients who had had
TIAs, 15 (14.4%) were seen on same day of
referral and 95 (91.3%) were seen within seven
days. These patients are seen within an average
of 3 days at the specialist clinic. Only nine
(8.7%) were not seen within 7 days.
Regarding when patients with suspected
TIAs contacted either GPs or hospital
doctors immediately after their symptoms
onset, 124 with suspected TIAs (26.3%)
went straight to a GP and/or hospital when
their stroke symptoms occurred and 348
(73.7%) presented themselves to a GP and/or
hospital within an average of 3 days of their
symptoms onset (Figure 5).
Discussion
Stroke and TIA mimics
One in every five TIAs is a TIA mimic (Amort
et al, 2011). From the authors experience, the
rate suspected TIAs that are mimics is 46%.
TIA mimics can include epileptic seizures,
migraine attacks, syncope, hypoglycaemia,
brain tumours and subdural haematomas.
Some patients with TIA mimics had all
their investigations performed on the same
day as their appointment, these include
CT scans, carotid doppler, bloods and
electrocardiograms.
The low rate of referral of patients with
symptoms that mimic a TIA might be related
to a lack of education in GPs and other
health professionals, such as A&E doctors;
this would result in people not being referred
when they should be.
On the other hand, the TIA clinic is
the place to identify stroke patients. Of
the patients seen in the clinic, 7% had a
confirmed diagnosis of a stroke. Diagnosis
is based on clinical presentation and the
result of CT scans. It was unfortunate that
the referring GPs and A&E doctors did not
identify stroke when patients first presented
to their surgery or hospital. Continuous
education for GPs, focusing on assessment
and diagnosis of TIAs, is therefore imperative.
Probable TIA Mimic Stroke
Figure 1. Number of transient ischaemic attacks (TIAs)
seen in the specialist clinic
High risk: ABCD2 score of 4
Low risk: ABCD2 score <3
Figure 2. Risk stratification of patients who had had a
probably TIA
100
90
80
70
60
50
40
30
20
10
0
On the day
of referral
<24hrs Not seen
within 24 hrs
Figure 3. How soon patients with high-risk TIAs are seen
in the specialist clinic
104
(46%)
122
(54%)
51
(41.8%)
95
(94.2%)
6
(5.8%)
216
(46%)
226
(48%)
30
(6%)
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Stroke patients identified at the TIA clinic
were immediately admitted to a hyper-
acute stroke unit for further treatment
and management using a multidisciplinary
approach. HfL (2009) designated the hyper-
acute stroke unit as a new model for providing
a specialist stroke service during the first
2472 hours before patients are transferred to
a local stroke unit for further rehabilitation.
Several benefits of the new London stroke
model include a shorter stay in hospital, direct
admission to the stroke unit and provision of
thrombolysis treatment (NHS London, 2010).
High-risk and low-risk TIAs
Nearly all patients with TIAs (94.2%) were
seen within 24 hours. Of these, 41.8% were
seen on the day they were referred by their
GP or A&E doctor. This shows that the
TIA clinic can see these patients promptly
when necessary. A clear history from the GP
regarding TIA events, risk factors for stroke,
ABCD2 score and clinical presentations were
deciding factors that helped doctors and nurses
to decide who needed to be seen urgently.
The results from our TIA clinic, reported
here, show it provides good clinical practice as
it sees patients with high-risk TIAs at the time
of referral, rather than waiting to see them
within 24 hours. The data also shows that the
specialist TIA clinic exceeded HfLs target of
seeing 90% of these patients within 24 hours.
As far as low-risk TIAs are concerned,
91.3% were seen within an average of three
days. Of these, 14.4% were seen on the day
of referral. HfL recommends that 90% of
low-risk TIAs should be seen within 7 days,
so the TIA clinic exceeds HfLs performance
target. Only nine patients (8.6%) were not
seen within 7 days.
Delay of presentation of patient
from time of TIA onset
A majority (73.72%) of patients with
suspected TIAs presented themselves to their
GP and/ or hospital within an average of 3
days from the onset on symptoms.
Possible reasons for delay include:
Their choice of when to come to the GP
The patients lack of awareness of stroke/
TIA symptoms
The patient feeling that seeking urgent
medical attention was not needed since the
symptoms had resolved already
The GP delaying referral to the clinic
The refusal of the patient to undergo
assessment and investigation.
Chandratheva et al (2010) stress that
approximately 70% of patients do not
correctly recognise their TIA or minor stroke,
30% delay seeking medical attention for >24
hours, regardless of age, sex, social class or
educational level, and approximately 30% of
early recurrent strokes occur before attention
has been sought. Jurkowski et al (2008) also
say awareness of the specific symptoms of
stroke is poor among the general public.
However, Lasserson et al (2012) say that the
ability to recognise stroke-like symptoms is
not associated with seeking medical attention
or using emergency services earlier. Similar
findings in other studies (Schroeder et al, 2000;
Mosley et al, 2007; Ritter et al, 2007) suggest
there is a need to review the effectiveness and
impact of different information campaigns to
increase awareness of the public about stroke
and its symptoms(Marx, 2008).
There might be a future role for NHS 111
(which has replaced NHS Direct) in reducing
delays to assessment by acting as a coordinating
service, for example, by directing patients
to a stroke unit for assessment as part of a
comprehensive stroke and TIA care pathway.
However, few patients in this study used NHS
Direct and the advice given was not always
optimal, which limits the options for planning
integrated care (Lasserson et al, 2007).
Conversely, some patients can recognise
stroke symptoms but do not access emergency
medical attention (Ritter et al, 2007). Sprigg
et al (2008) say that a majority of delays in
seeking assessment after TIA is due to a lack
of response by the patientmany patients do
not recognise the symptoms of stroke/TIA
and, even when they do, many fail to seek
emergency medical attention.
When one takes all this into account, it
is clear that educating the public is vital,
particularly on the significance of contacting
or attending an emergency department
immediately after a TIA event.
Many patients present late after a TIA.
This delays intervention and the time of
presentation may partly depend on whether
patients first attend A&E or a GP surgery
(Manawadu et al, 2010).
Studying this behaviour could improve
stroke prevention through better targeting of
public education and allocation of resources
(Manawadu et al, 2010). Most patients
presenting to an emergency department go
urgently, whereas most going to a GP delay,
particularly at weekends (Manawadu et al,
2010). Most Canadian patients, particularly
those at high risk, go to an emergency
department whereas most UK patients go to
a GP. One way to reduce delay, particularly in
the UK, would be to direct all patients with
TIA to go to A&E rather than to their GP
(Manawadu et al, 2010).
To reduce recurrent stroke, GPs need to
ensure that patients with TIA or stroke are
recognised and assessed as soon as possible
after the event. This enables risk stratification
for urgency of assessment, with TIA patients
scoring 4 or more on the ABCD2 score
receiving specialist assessment with access
to investigations and treatment within 24
hours of symptom onset (NICE, 2008). GPs
should therefore understand how delays in
receiving specialist attention can be reduced
(Lasserson, 2012). Delayed presentation after
100
90
80
70
60
50
40
30
20
10
0
On the day
of referral
Within 7
days (mean
=3 days
Not seen
within 7
days
Figure 4: How soon patients with low-risk TIAs are seen
at the specialist clinic (%)
Figure 5. Time from onset of symptoms to contacting
healthcare professionals after a suspected TIA
Number of patients who contacted a
healthcare professional immediately
Number of patients who contacted a
healthcare professional within three days
15
(14.4%)
95
(91.3%)
348
(73.7%)
124
(26.3%)
9
(8.7%)
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the onset of TIA may increase the likelihood
of developing a devastating stroke. GPs should
be knowledgeable in recognising TIA as an
emergency condition and also realise that it
should be treated as stroke.
Conclusion and recommendations
TIA is an emergency condition. Incidence
is increasing because of an aging population.
Evidence shows that patients delay seeking
medical attention after a TIA event.
Public education is still the key to
increasing awareness about this condition.
It cannot be stressed too strongly that a
national education campaign should focus
not only on the recognition of stroke
symptoms but also on the availability of the
specialist service that provide rapid access
for TIAs, and should highlight to patients
the devastating consequences of not seeking
medical attention after a TIA has occurred.
GPs or A&E doctors should refer all
suspected TIAs to specialist TIA clinics
urgently. It would be interesting to find out
the numerous factors that affect how GPs
and A&E doctors refer patients to TIA clinics.
Patients behavioural factors affecting their
decision to seek medical attention after a TIA
event is an important area to research.
The TIA clinic described in this article
sees patients quickly, usually on the day the
referral is received or within 24 hours if they
are classified as high risk and within 3 days if
they are thought to be at low risk.
The rate of TIA mimics is high. Some of
them receive all TIA investigations such as
CT scans and carotid doppler tests, as well as
treatments. It would be interesting to find out
the cost implications of TIA mimics receiving
unnecessary treatments and diagnostic tests.
A review of referral letters received from
the GPs or A&E doctors could be carried out
to find out how many patients are referred
who should not be referred to the TIA clinic.
Further research is needed to identify the
factors that cause the GPs to delay referring
their patients to the specialist TIA clinic.

BJN
Conflict of interest: none
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KEY POINTS
n Transient ischaemic attacks (TIAs) are an emergency condition
n Patients with high-risk TIAs should be seen within 24 hours and those with low-risk TIAs
within 7 days of symptom onset. It is good practice to see high-risk TIAs on the day the
patients are referred to the clinic. The ABCD2 scoring system helps to assess risk levels
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of stroke or TIA. A national campaign to increase public awareness about the impact of not
seeking medical attention promptly could help tackle this
n GP education around triage, assessment and in identifying TIA mimics is imperative if TIAs
are to be diagnosed accurately and referrals made to specialist TIA clinics promptly
n An urgent referral to the TIA clinic is key to avoiding delays in accessing specialist
assessment and management.
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