TIA & Stroke
Red Flags — act before continuing history
| Red flag | Why dangerous | Action |
|---|---|---|
| Neurological symptoms still present (face droop, arm weakness, speech difficulty persisting NOW) | Ongoing symptoms = acute ischaemic stroke — NOT a TIA. Every minute without reperfusion = 1.9 million neurons lost. Time to thrombolysis or thrombectomy is the determinant of outcome. Do not take a history — call 999. | 999 immediately |
| Sudden thunderclap headache ("worst headache of my life") maximal at onset | Subarachnoid haemorrhage (SAH) — 30–50% mortality. Do NOT give aspirin until haemorrhage excluded by CT. Any focal neurology + sudden severe headache = haemorrhagic stroke or SAH until proven otherwise. | 999 — exclude SAH first |
| Progressive worsening of neurological deficit since onset | Stroke-in-progression — likely large vessel occlusion amenable to mechanical thrombectomy. Every minute of delay reduces probability of good outcome by 2%. Do not monitor in GP surgery. | 999 immediately |
| Sudden onset vertigo + vomiting + ataxia + depressed consciousness | Posterior fossa stroke or haemorrhage — basilar artery territory. Rapid brainstem compression and tonsillar herniation can cause respiratory arrest within minutes. Misdiagnosed as labyrinthitis in a significant proportion of cases. | 999 immediately |
| Young patient (under 50) + unilateral neck or occipital pain + TIA symptoms | Carotid or vertebral artery dissection — often after minor trauma, chiropractic manipulation, or coughing. Thrombus forms on the intimal tear and embolises. Anticoagulation is preferred over antiplatelet in dissection. | Same-day neurovascular |
| Crescendo TIA — second or third episode within days, or multiple episodes within hours | Up to 20% stroke risk within 48 hours. The highest short-term stroke risk scenario in primary care. Requires immediate admission or same-day specialist assessment regardless of ABCD² score. | Same-day emergency admission |
Safeguarding Considerations — Consider in Every Consultation
🏠 Domestic Abuse / Strangulation
- Strangulation is strongly associated with carotid artery dissection — can present days to weeks after the assault as TIA or stroke
- Young woman with TIA and no conventional vascular risk factors: always consider intimate partner violence, even if she does not volunteer it
- Signs: bruising to neck, petechial haemorrhages in conjunctivae, hoarse voice, difficulty swallowing — all consistent with strangulation injury
- Carotid dissection from strangulation changes management to anticoagulation — the abuse history is clinically as well as legally essential to document
👴 Older Adults & Post-Stroke Vulnerability
- TIA symptoms in elderly patients are frequently dismissed as "dizziness" or "old age" by carers — be alert to delayed or incomplete presentation
- Post-stroke cognitive impairment increases vulnerability to financial exploitation, coercion, and carer-directed harm
- Medication tampering: deliberate omission of antiplatelets or anticoagulants by a carer increases stroke recurrence risk — if adherence appears poor, explore who manages the medication
- Isolated elderly patient with new cognitive change post-TIA: formal capacity assessment and social care referral may be required
🧒 Children / Young Adults
- Stroke or TIA in a child or young adult is always a safeguarding alert — consider physical abuse, fabricated/induced illness, or substance misuse imposed by another
- Sickle cell disease increases stroke risk dramatically in children — ensure pain crises and stroke prevention hydroxycarbamide plans are in place and reviewed
- Adolescent using OCP or illicit substances: non-judgmental exploration essential; OCP with migraine with aura is an absolute contraindication that must be addressed
- Unaccompanied young person with unexplained stroke: involve safeguarding lead early; thorough social history mandatory
💊 Medication Misuse / Self-Harm
- Over-anticoagulation (supratherapeutic warfarin / DOAC accumulation) can cause intracranial haemorrhage — consider deliberate overdose in suicidal patients
- Deliberate non-adherence to prescribed antiplatelets as indirect self-harm: explore mood and ideation in patients with poor secondary prevention compliance
- Stimulant or cocaine use causing stroke: non-judgmental enquiry; urine toxicology without patient knowledge is not appropriate — always explain the clinical reason
- Post-stroke depression (30% within 1 year) is a major independent risk factor for poor secondary prevention adherence — screen routinely with PHQ-9
🚗 Driving and Independence
Losing the ability to drive — even temporarily — can feel catastrophic to an independent person, particularly in rural areas or for someone who provides for family members. DVLA restrictions (1 month off driving after TIA or stroke for a car licence; 1 year for bus/lorry licences) can precipitate significant psychological distress and social isolation, and may lead to concealment of symptoms at future consultations to avoid further restriction.
"I need to be honest with you about driving — legally, you can't drive for one month after a TIA. I know that sounds difficult, especially with your grandchildren. Let's talk about what's available for support in the meantime, and what the pathway back to driving looks like."Document DVLA advice in notes. If patient refuses to stop driving: GMC guidance requires you to report to DVLA if a patient with a notifiable condition continues to drive against medical advice.
😨 Acute Fear and Health Anxiety
The sudden neurological event triggers intense fear of imminent stroke. Some patients develop health anxiety or panic disorder after TIA — interpreting any physical sensation as a recurrence. This can paradoxically reduce engagement with secondary prevention (avoidance of exercise due to fear of triggering a stroke) and significantly impair quality of life.
"What happened this morning must have been incredibly frightening. The most important thing I want you to know is that by coming in today and starting treatment, you're doing the right thing to dramatically reduce the chance of it happening again."NHS Talking Therapies referral for health anxiety post-TIA. Specific psychoeducation about safe activities (moderate exercise is protective, not harmful) reduces avoidance behaviour.
😔 Post-Event Depression
Post-stroke depression affects 30% of patients within the first year and is the strongest predictor of poor rehabilitation outcomes and poor secondary prevention adherence. Even after TIA without residual deficit, the psychological impact can be equivalent. Depression is frequently missed because it overlaps with normal adjustment reactions and is not routinely screened.
"Over the next few weeks and months, it's really common to feel low, anxious, or not quite yourself after an event like this. I'd like to check in with you about your mood at our next appointment — there's a lot of support available if that happens."PHQ-9 at every post-TIA/stroke review. Consider an antidepressant when clinically indicated, with particular care in people taking antithrombotics — SSRIs are not given to prevent recurrence. Refer to NHS Talking Therapies for CBT or to SALT/psychology as appropriate.
👨👩👧 Family and Carer Impact
The carer of a TIA or stroke patient often carries acute anxiety that is not addressed in the consultation focused on the patient. Carer burden increases the risk of patient neglect. The role reversal — when a previously capable person suddenly becomes dependent — strains relationships. Secondary prevention adherence is higher when a family member is engaged in the management plan.
"Is there someone important to you who should know what happened today and what the plan is? With your permission, it sometimes helps to involve a family member in understanding what to watch out for."Carer's assessment referral if significant carer burden. Stroke Association family support resources. Named family contact for safety-netting (emergency red flag recognition).
💼 Employment and Cognitive Impact
Even a TIA without visible deficit can cause subtle cognitive impairment — slowed processing, memory difficulties, concentration problems — that affect work performance. Post-stroke cognitive impairment (PSCI) affects up to 30% of stroke survivors. Some professions (professional drivers, surgeons, pilots, teachers working with heavy machinery) have specific fitness-to-work regulations triggered by TIA or stroke.
"Have you been back to work since this happened? I'd like to talk about what your job involves — some roles have specific rules about returning to work after a TIA, and I want to make sure we manage that properly for you."MED3 fit note with specific functional limitations. Occupational health referral for regulated professions. Cognitive assessment (MoCA or MMSE) at post-TIA reviews. Vocational rehabilitation referral if employed and cognitively affected.
🌍 Health Literacy and Cultural Context
TIA is frequently missed by patients and clinicians from all backgrounds but cultural beliefs about stroke as divine punishment, the role of stress, and resistance to "blood thinners" are particularly common across several South Asian and African-Caribbean communities. In these contexts, the explanation of mechanism and the framing of secondary prevention as life-preserving rather than illness-defining is especially important.
"Different people understand these events differently. Can I ask — what does this mean to you? And is there anything about the treatment I'm suggesting that feels difficult or doesn't quite fit with your understanding?"Interpreter services for non-English speakers at first presentation — do not use family members to translate for consent discussions. Written information in appropriate language. Community health advocates for ongoing secondary prevention support.
- Not checking whether symptoms are still present before taking a history (ongoing deficit = 999, not consultation)
- Giving aspirin to a patient with ongoing deficit before brain imaging, or when aspirin is contraindicated (bleeding disorder, on an anticoagulant) — for resolved suspected TIA, NICE NG128 says offer aspirin 300 mg immediately
- Failing to ask about AF before defaulting to antiplatelet therapy
- Not asking about OCP in a woman of reproductive age — OCP + TIA = stop OCP immediately
- Leaving DVLA advice until the end as an afterthought — it is a central part of this consultation
- Reassuring the patient that "it has gone away so it should be fine" without risk stratification
999 or Immediate Admission
Call 999 / Send directly to stroke unit- Ongoing neurological deficit (stroke in progress)FAST positive with persistent symptoms — every minute counts; hyperacute thrombolysis or thrombectomy window
- Thunderclap headache ± focal neurologySAH or haemorrhagic stroke — do NOT give aspirin; CT head immediately
- Crescendo TIA (2 or more episodes in 7 days)Very high early stroke risk — same-day stroke-specialist assessment; admit if ongoing symptoms or high-risk features
- Posterior fossa signs: ataxia + vomiting + depressed consciousnessBasilar artery territory stroke — risk of tonsillar herniation; do not wait
- Young patient with neck pain + TIA symptomsCarotid or vertebral artery dissection — requires anticoagulation; MR angiography urgently
Same-Day Specialist Assessment
Within 24 hours (NICE NG128)- All suspected TIA (≤7 days)Specialist assessment within 24h (NG128 — do not use ABCD² to set urgency); give aspirin 300mg now
- TIA with confirmed or suspected AFAnticoagulation decision must be made same day — do not delay for outpatient appointment
- TIA despite existing antiplatelet therapyBreakthrough event = treatment failure; urgent assessment for cause (AF? carotid? compliance?)
- First TIA with new carotid bruit on auscultationUrgent Doppler to exclude significant stenosis — symptomatic 50–99% → urgent vascular referral; surgery ideally within 7 days
- Posterior circulation TIA (diplopia, vertigo, ataxia, dysphagia)Higher early stroke risk than anterior TIA — same-day referral regardless of ABCD²
Urgent Outpatient / GP-Led
TIA clinic within 7 days- TIA more than 7 days agoAspirin 300mg started; specialist assessment within 7 days (NG128) — recent TIA is never routine
- Established TIA/stroke — secondary prevention reviewBP, statin adherence, antiplatelet/anticoagulant review; PHQ-9 mood screen
- Post-stroke rehabilitation progress reviewCo-ordinate physio, OT, SALT, psychology; driving and work return planning
- Post-TIA monitoring: BP target reached, cholesterol optimisedAnnual cardiovascular risk review; smoking cessation update
- DVLA notification follow-upConfirm DVLA notification where required (residual deficit, multiple TIAs or Group 2); document in notes; arrange driving assessment at appropriate time
- Not offering aspirin 300 mg immediately for resolved suspected TIA (NICE NG128), or giving it despite a contraindication (bleeding disorder, anticoagulant — these need urgent imaging first)
- Not communicating urgency — "you can come back next week if it happens again" is dangerous
- Failing to give aspirin 300mg loading dose when indicated — not 75mg, not clopidogrel alone
- Sending patient home without a plan for same-day or next-day specialist assessment for high-risk TIA
- Not checking blood glucose — hypoglycaemia is the most common stroke mimic
- Omitting pulse assessment — AF drives the entire management pathway
- Skipping carotid auscultation — carotid bruit mandates urgent Doppler
- Failing to re-examine for residual neurological deficit — if deficit persists = ongoing stroke = 999
- Giving aspirin before brain imaging in a patient with ongoing stroke symptoms, a bleeding disorder or an anticoagulant — antiplatelet in haemorrhagic stroke can be fatal (resolved suspected TIA: aspirin 300 mg without imaging, NICE NG128)
- Omitting ECG for AF screening — this changes management entirely
- Not explaining what carotid imaging is for — patient may decline a scan they don't understand
- Ordering all investigations without explaining which is needed urgently vs routinely
- Missing blood glucose — the most common TIA mimic is completely reversible hypoglycaemia
"What happened this morning is called a TIA — a transient ischaemic attack — which most people call a mini-stroke. Think of it like a warning light on your dashboard: the blood supply to part of your brain was briefly cut off — for about 20 minutes — and thankfully it came back before any permanent damage was done. The symptoms went away because blood flow restored itself. But here's the important thing: a TIA is your brain sending you an urgent warning signal. Without treatment, the risk of a full stroke in the next week is around 10%, and that's a stroke that may not go away. The good news is that if we act today — and we will — that risk can be dramatically reduced."
"It was probably just a funny turn — it's gone now, so it can't be serious."
"I understand why it feels that way, because you feel completely well right now — and that's genuinely reassuring. But the way it came on suddenly, the specific symptoms you had, and the fact it resolved completely are all very consistent with a TIA. And unfortunately, the fact that it resolved doesn't mean the risk has gone — it means the warning light has come on. The most important moment to prevent a stroke is the few days right after a TIA, which is why I want to act today."
"My GP said my blood pressure is a bit high but it's never caused any problems."
"That makes sense — high blood pressure doesn't usually cause obvious symptoms until it causes a problem like this. What's actually happened today is that your blood pressure has been quietly narrowing and straining the blood vessels in your brain over time, and today that process has shown itself. The really positive thing is that we know exactly what to do — treating the blood pressure is one of the most effective things we can do to reduce your risk significantly."
Ischaemic Stroke (symptoms persist)
Ongoing focal deficit >24h or DWI-positive lesion. NIHSS grading. Hyperacute management in stroke unit. Thrombolysis if <4.5h; thrombectomy if large vessel occlusion and <24h.
Symptomatic Carotid Stenosis 50–99%
TIA + ipsilateral carotid stenosis 50–99% = urgent vascular referral. Endarterectomy, ideally within 7 days of symptom onset, is the most effective secondary prevention intervention.
Cryptogenic Stroke / Young Stroke
Under 60, no AF, no carotid stenosis, no obvious risk factors. PFO investigation; thrombophilia screen; vasculitis screen; drug toxicology. Neurology referral.
Subarachnoid Haemorrhage
Thunderclap headache maximal at onset. CT head: hyperdense blood in subarachnoid space. LP if CT negative within 12h (xanthochromia). 999 immediately — neurosurgery. Do NOT give aspirin.
Intracerebral / Posterior Fossa Haemorrhage
Progressive focal deficit + HTN + anticoagulant use. CT hyperdensity in parenchyma or posterior fossa. Risk of herniation. 999. Reverse anticoagulation immediately.
- Using "TIA" or "ischaemic attack" without explaining what it means in plain language
- Saying "it's just a mini-stroke" without conveying the urgency of the warning it represents
- Not giving any risk statistics — the 10% 7-day stroke risk is the motivating fact
- Not directly addressing the patient's attribution of the episode to "stress" or "nothing"
- Referring without starting secondary prevention — aspirin, statin, and BP management should all be initiated by the GP at first contact
- Not telling the patient what the referral is for or what will happen at the clinic
- Missing DVLA advice at this consultation — this is a primary care responsibility, not a specialist responsibility
- Referring any recent TIA as routine — ALL suspected TIA within the last 7 days need specialist assessment within 24 hours (NG128)
Validate — name their expectation
Most TIA patients expect reassurance that "it was nothing." Their expectation is that because symptoms resolved, the problem has resolved. Validating this expectation explicitly — before challenging it — creates the psychological safety to hear the more difficult truth.
"I completely understand why you think that — it went away, you feel fine, and you drove yourself here. That makes complete sense. Can I explain why, despite that, I'm taking this very seriously today?"Explain — share your clinical reasoning
Explain the 10% 7-day stroke risk in a way that is concrete and personally relevant. Connect the risk to what they care about — their grandchildren, their independence, their driving. Not as a threat but as a reason to act together.
"Without treatment, there's roughly a 10% chance of having a larger stroke in the next week. That's a stroke that might not go away. With treatment started today, we can reduce that risk dramatically. That's why I'm asking us to act now rather than watching and waiting."Negotiate — offer something today
Frame the secondary prevention cascade as immediate, actionable, and empowering. The patient should leave knowing exactly what is different from today, and feeling that they are doing something to protect their future — not just having things done to them.
"Here's what I want to do today: give you an aspirin to take now, start a cholesterol tablet, check your blood pressure, book you into the specialist clinic, and give you a clear plan for what to watch out for. By the end of today, you'll already be significantly better protected."Smoking doubles ischaemic stroke risk via endothelial dysfunction, accelerated atherosclerosis, platelet activation, and increased fibrinogen. Risk returns to non-smoker level within 5 years of cessation.
Behavioural support plus varenicline, cytisinicline, combination NRT (patch + short-acting) or a nicotine vape — the options NICE NG209 rates most likely to work; refer to the NHS Stop Smoking Service; set a quit date timed to the chosen option. A TIA is the most powerful teachable moment — use it.
Hypertension is the single most important modifiable stroke risk factor. Each 10 mmHg systolic reduction = 25–30% reduction in stroke recurrence. DASH diet (Dietary Approaches to Stop Hypertension) achieves ~11 mmHg systolic reduction.
Reduce salt to <6g/day (no added salt, avoid processed foods). Increase fruit and vegetables to ≥5 portions/day. Reduce alcohol to <14 units/week. Weight loss if BMI >25 (each 10kg = 6 mmHg reduction).
Heavy alcohol intake (≥3 units/day) causes AF via "holiday heart" effect, drives hypertension, and increases haemorrhagic stroke risk by 2×. Heavy drinking also destabilises INR on warfarin. Moderate alcohol (<14 units/week) does not significantly increase stroke risk.
AUDIT-C screening. Brief structured intervention. SMSC referral if dependent. Track units using NHS Drink Free app. Avoid binge drinking pattern (AF trigger) even at lower weekly totals.
Regular aerobic exercise reduces BP, improves endothelial function, reduces platelet aggregation, and reduces AF risk. Regular exercise (150 min moderate/week) reduces stroke risk by ~25% in observational studies. After TIA with no residual deficit, exercise can resume within days.
Brisk walking 30 minutes 5 days/week is sufficient. Swimming, cycling, or dancing are alternatives. Resistance training 2× per week for blood pressure benefit. Advise patient that moderate exercise is safe and protective — not a stroke trigger.
Mediterranean diet (olive oil, fish, legumes, vegetables, nuts, reduced red meat) reduces stroke recurrence by ~30% (PREDIMED trial). Mechanisms: anti-inflammatory, antioxidant, reduced platelet aggregation, BP lowering, and improved glycaemic control.
Replace butter with olive oil. Two portions of oily fish per week. Replace red meat with legumes/pulses ×2/week. 5+ fruit and vegetable portions daily. Reduce ultra-processed foods. Dietitian referral if significant overweight or food insecurity.
Obstructive sleep apnoea (OSA) is a significant but underrecognised stroke risk factor — present in up to 60% of stroke patients. OSA causes intermittent hypoxia, BP spikes, endothelial damage, and nocturnal AF episodes. CPAP treatment reduces stroke recurrence and improves BP control.
Screen with STOP-BANG questionnaire at post-TIA review. Refer to respiratory medicine / sleep clinic if score ≥3. CPAP: significant BP reduction (equivalent to one antihypertensive). Weight loss improves OSA in obese patients.
Aspirin 300mg stat (loading dose) — give at the GP consultation
- Suspected TIA with resolved symptoms: give aspirin 300mg immediately unless contraindicated (NICE NG128). Bleeding disorder or on an anticoagulant: do not give — admit for urgent imaging. Ongoing deficit (stroke): aspirin only after brain imaging excludes haemorrhage
- Do NOT give 75mg — 300mg is the loading dose; 75mg is the maintenance dose only
- If AF present or strongly suspected: give aspirin as bridge only; initiate DOAC same day
- Clopidogrel + aspirin (DAPT) for high-risk TIA/minor stroke is specialist-initiated after assessment — not for all TIA presentations
If specialist-initiated (high-risk TIA/minor stroke): clopidogrel 75mg + aspirin 75mg for 21 days, then clopidogrel monotherapy
- Atorvastatin 80mg OD — start promptly; ischaemic TIA regardless of baseline LDL unless contraindicated or no atherosclerosis (NICE NG238)
- Antihypertensive — per NG136: CCB (amlodipine) if 55 or over or Black African/African–Caribbean origin, ACEi/ARB if under 55 or diabetic; then A+C; target clinic systolic <130 if tolerated
- Dual antiplatelet for 21 days then switch to clopidogrel 75mg monotherapy long-term
- PPI (lansoprazole 30mg) if dual antiplatelet — reduces GI bleeding risk
DOAC (apixaban/rivaroxaban/edoxaban) — start based on stroke severity
- TIA or minor stroke: start DOAC within 24 hours
- Moderate stroke (NIHSS 8–15): start DOAC at 3 days (1-3-6-12 rule)
- Severe stroke (NIHSS ≥16): start DOAC at 12–14 days
- Stop aspirin once DOAC established and therapeutic. No dual antiplatelet + DOAC unless specific cardiology indication.
- Symptomatic carotid stenosis 50–99% + ipsilateral TIA → urgent vascular referral; CEA ideally within 7 days
- Stenting is an alternative in selected patients; specialist decision
- Stenosis <50% → medical management only; CEA not indicated
- Benefits of CEA fall with delay — aim for within 7 days — do not delay Doppler result or referral
- CEA reduces stroke risk from ~25% to <5% within 2 years for >70% stenosis
- Haemorrhagic stroke: no antiplatelet or anticoagulant in acute phase; BP <140/90; neurosurgery if haematoma expanding
- Lobar haemorrhage on anticoagulant: reverse anticoagulation immediately; restart decision at 4–8 weeks with neurology
- Young stroke (<60, cryptogenic): PFO closure if <60, DWI-positive, no AF (CLOSE/REDUCE trial criteria)
- Pregnancy: low-dose aspirin safe in T2/T3; LMWH preferred anticoagulant; warfarin contraindicated T1; DOAC absolutely contraindicated throughout
- Antiphospholipid syndrome: warfarin preferred over DOAC for arterial events
- Atrial fibrillation confirmed (ECG or history)
- Non-AF ischaemic TIA / stroke
- Carotid stenosis >50% on Doppler
- Haemorrhagic stroke (intracerebral or SAH)
- Young patient (<60) / cryptogenic mechanism
- Hypertension requiring treatment
"I'm giving you a high-dose aspirin to take now — 300mg — this is a loading dose to thin the blood quickly. After today, you'll take a lower dose of 75mg. The TIA clinic may add a second tablet, clopidogrel, for the first 3 weeks — together they can give better protection early on."
Loading dose is 300mg, NOT 75mg — this is one of the most common prescribing errors in TIA management in SCA. Stating "aspirin 300mg now" explicitly = Tasks mark. Do not give it without imaging if symptoms persist (possible stroke) or the patient has a bleeding disorder or takes an anticoagulant — state this explicitly.
"You'll be taking two blood-thinning tablets together for the first 3 weeks — aspirin and clopidogrel. After 3 weeks, you'll stop the aspirin and continue just the clopidogrel long-term. The combination is much more effective in the first few weeks, but for long-term use the clopidogrel alone is better."
The dual antiplatelet for 21 days then clopidogrel monotherapy is the regimen in the National Clinical Guideline for Stroke (ICSWP, 2023) for high-risk non-AF TIA or minor stroke, started by the stroke specialist. In SCA: stating the 21-day switch explicitly = Tasks mark. Continuing dual antiplatelet indefinitely = prescribing error.
"This blood thinner works specifically because of your irregular heart rhythm — it prevents blood clots forming in the heart and travelling to the brain, which is what caused your TIA. It's taken every day, and it's important not to miss doses. Unlike warfarin, you don't need regular blood tests to monitor the level."
In SCA: AF + TIA → DOAC replaces antiplatelet. Stating this switch explicitly with the mechanism ("in AF the risk is clot from the heart, not arterial plaque, so anticoagulation is much more effective than antiplatelet") = high-value Tasks mark.
"This cholesterol tablet is an important part of reducing your risk of a future stroke. We start at a high dose — 80mg — because your blood vessels have already shown signs of damage. Take it in the evening. If you get muscle aches or pain, let me know — most people tolerate it very well."
In SCA: atorvastatin 80mg must be mentioned specifically — not just "a cholesterol tablet." Stating the indication ("high-intensity statin for all ischaemic TIA regardless of cholesterol level") = Tasks domain mark. Haemorrhagic stroke = do NOT start without specialist review.
"Your blood pressure is one of the most important things we can treat to prevent a stroke from happening again. We'll start at a low dose and build it up over a few weeks to reach a safe target. The first dose can sometimes make you feel a little lightheaded — take it at night to begin with."
Timing of antihypertensive post-stroke is a common SCA pitfall: do NOT lower BP aggressively in acute stroke (first 72h). Post-TIA: start within days. PROGRESS trial evidence: indapamide + perindopril combination showed greatest secondary prevention benefit regardless of baseline BP.
"This is a clot-busting treatment that we give through a drip directly into a vein. It works by breaking up the clot that's blocking the artery in your brain. It has a small risk of causing bleeding in the brain, but in your case the benefit of trying to restore blood flow far outweighs that risk."
In SCA for GP setting: alteplase is a hospital-only treatment. The GP role is to call 999 immediately for suspected acute stroke — not to administer thrombolysis. Demonstrating knowledge of the thrombolysis time window (4.5 hours) and the reason for 999 urgency = Tasks mark.
Driving, DVLA & Independence
DVLA Group 1 (cars/motorcycles): must not drive for 1 month after TIA or stroke. Need not notify DVLA unless a residual neurological deficit persists after 1 month, or after multiple TIAs. Group 2 (HGV/PCV): must notify DVLA; typically 1 year minimum off; stricter fitness standards apply.
Refusal to notify DVLA: GP duty to advise the patient that they have a legal obligation to notify DVLA. If patient refuses and continues to drive: contact DVLA directly after warning the patient — GMC guidance supports this breach of confidentiality to prevent serious harm.
Driving return: after appropriate period and clinical clearance, OT driving assessment may be required (especially post-stroke with residual deficit). Document all driving advice in every consultation.
"I have to be straightforward with you about driving — you legally cannot drive for one month after a TIA. I know that's difficult, especially with the grandchildren. Let me explain exactly what the pathway back to driving looks like, and what you need to do with DVLA."Post-TIA / Post-Stroke Depression
Post-stroke depression affects 30–40% of patients within the first year and is the most important predictor of poor rehabilitation outcomes, non-adherence to secondary prevention, and increased mortality. Even after TIA without persistent deficit, adjustment disorder and health anxiety are common.
Depression is frequently undetected — patients attribute low mood to "understandable" consequences of a frightening event rather than a treatable condition. PHQ-9 at every post-TIA/stroke review is mandatory, not optional.
Offer psychological and social interventions; consider an antidepressant (e.g. sertraline or citalopram) when clinically indicated, with care in people taking antithrombotics — it is not given to prevent recurrence. Escitalopram reduces post-stroke emotional lability. NHS Talking Therapies referral for CBT if subclinical or moderate depression.
"How has your mood been since this happened? It's really common to feel low or anxious after a TIA — not a sign of weakness, just a normal response to something frightening. There's very effective treatment available, and feeling better makes it easier to keep up everything that protects you."Employment & Cognitive Impact
Even TIA without residual deficit can cause subtle cognitive impairment: slowed processing speed, working memory difficulties, fatigue, and word-finding problems. These may be invisible to observers but significantly affect work performance, particularly in knowledge-intensive or safety-critical roles.
Regulated professions (surgeons, pilots, professional drivers, police, armed forces) have specific fitness-to-work rules triggered by TIA or stroke — many require formal occupational health assessment before return to work. GPs must identify these professions and initiate appropriate pathways.
Cognitive assessment: MoCA (Montreal Cognitive Assessment) is the recommended brief tool post-stroke in primary care. Refer to neuropsychology if cognitive concerns on formal testing. Vocational rehabilitation for return to complex work roles.
"Have you been back to work since this happened? I'd like to ask about your job specifically — some roles have particular rules about returning after a TIA, and I want to make sure we manage that properly for you and your employer."Family, Carer Burden & Relationships
The sudden role reversal after TIA — when an independent person becomes, even briefly, dependent — strains relationships. The partner or carer may experience acute anxiety, grief, and burnout that is rarely addressed in the medical consultation focused on the patient.
Carer anxiety can paradoxically reduce patient independence: over-protective partners may prevent the resumption of normal activities, including exercise, which is protective against recurrence. Carer psychoeducation about safe activities is as important as patient counselling.
Secondary prevention adherence is significantly higher when a family member understands the management plan. With patient consent, brief carer education at the same appointment or a follow-up call dramatically improves long-term outcomes.
"Is there someone important in your life who should know what happened today and what the plan is? With your permission, sometimes involving a family member in understanding what to watch out for makes a big difference to how well you both cope."Post-Stroke Cognitive Impairment (PSCI)
Post-stroke cognitive impairment affects up to 30% of stroke survivors and 15–20% of TIA patients. Vascular cognitive impairment (VCI) ranges from mild cognitive impairment to vascular dementia. Atrial fibrillation-related strokes carry particularly high dementia risk (NOAC therapy reduces this).
PSCI is often undiagnosed in primary care because patients compensate with strategies and carers accommodate the change. Screening for cognitive deficits after stroke is recommended in NICE NG236 (2023) — for example at follow-up reviews — but is frequently not performed.
Management: vascular risk factor control is the only currently evidence-based treatment to slow VCI progression. Cholinesterase inhibitors are not licensed for VCI but may be used off-label in mixed dementia. Referral to memory clinic if significant impairment.
"I'd like to do a brief memory and thinking test today — it only takes 5 minutes. This helps us get a baseline, so that if you or your family notice any changes in memory or thinking in the future, we have something to compare with."Rehabilitation & Return to Activities
Patients commonly fear that any physical exertion will trigger a recurrence — and become overly sedentary as a result. This avoidance behaviour is itself harmful: physical inactivity increases stroke recurrence risk. Clear, specific guidance about safe activities is essential.
Moderate aerobic exercise (brisk walking, swimming, cycling) can be resumed within days of a TIA with no residual deficit. Resumption of driving (at the appropriate time), sex, and travel (including flying) should all be discussed — patients are often too embarrassed to ask and remain unnecessarily restricted.
Structured stroke rehabilitation after stroke involves physiotherapy (mobility, balance), occupational therapy (ADLs, home assessment), and speech and language therapy (communication, swallowing). Referral coordination is a key primary care role in post-stroke management.
"I want to reassure you that gentle exercise is not only safe after a TIA — it's one of the best things you can do to prevent another one. Start with walking and build up gradually. Exercise reduces stroke risk, so please don't be afraid of it."Within 24 Hours — TIA Clinic / Neurovascular Assessment
TIA clinic: MRI DWI, carotid Doppler, echocardiogram, 24h cardiac monitoring, blood tests (lipids, HbA1c, thrombophilia if young). Antiplatelet regimen confirmed. BP treatment reviewed. DVLA advice confirmed and documented. If symptomatic carotid stenosis 50–99%: urgent vascular referral (CEA ideally within 7 days).
2–4 Weeks — GP Review
Review TIA clinic letter and investigations. Confirm dual antiplatelet 21-day course (then switch to clopidogrel). BP assessment and antihypertensive titration. Statin tolerance (myalgia?). PHQ-9 mood screen. Smoking cessation update. DVLA position confirmed (notification needed only if residual deficit, multiple TIAs or Group 2). Driving return planning if appropriate.
6–8 Weeks — Secondary Prevention Review
Antiplatelet switch: if dual antiplatelet period complete, confirm switch to clopidogrel 75mg monotherapy. LDL check: target ≤2.0 mmol/L (non-HDL ≤2.6) on atorvastatin 80mg. BP target review. HbA1c and glucose if DM. Cognitive screen (MoCA) — baseline for future comparison. Smoking and alcohol update. Driving assessment update.
3–6 Months — Stability Review
Confirm all secondary prevention medications established and tolerated. PHQ-9 — post-stroke depression peaks at 3 months. Review occupational impact and driving status. Carotid endarterectomy outcome if surgery performed. Cardiac monitoring result actioned (paroxysmal AF detected → anticoagulation). Referral to stroke-related support services (Stroke Association, community rehab).
Annual — Long-Term Secondary Prevention
Annual cardiovascular risk review: BP, LDL, HbA1c, BMI, smoking status, alcohol. Antiplatelet or anticoagulant adherence. DOAC: renal function review for dose adjustment. PHQ-9 and cognitive screen (MoCA). DVLA status update. Exercise, diet, sleep apnoea screen. Any new AF symptoms → 24h ECG. Liaise with neurovascular team if recurrent symptoms.
Memory rule
Post-TIA secondary prevention targets: BP <130/80 · LDL ≤2.0 mmol/L on atorvastatin 80mg · HbA1c individualised (usually 48 mmol/mol; 53 on a hypo-causing drug, NICE NG28) if diabetic · INR 2.0–3.0 if warfarin · clopidogrel monotherapy after 21 days dual antiplatelet. DOAC: annual renal function for dose adjustment. PHQ-9 at every review — post-stroke depression is the most missed and most treatable complication.
⚠ Three scenario-specific phrases — use these verbatim
Why safety-netting matters beyond clinical care
- Not giving BE-FAST safety-net — this is the most important safety-net in this topic
- Not mentioning DVLA restriction at closing — must be stated and documented at every TIA consultation
- Giving 75mg aspirin instead of 300mg loading dose — prescribing error consistently flagged in SCA
- Not closing with a genuine "is there anything else?" — the driving concern or family worry may emerge here
- Not naming a specific follow-up timeframe ("come back if things change" is not a named follow-up)
- Not acknowledging the emotional impact of the event — completing the clinical plan without addressing the person is a Relating to Others deduction
- Urgency communicated correctly: all suspected TIA → specialist review within 24h (NG128 — no score-based triage)
- Aspirin 300mg loading dose (not 75mg) stated explicitly
- Atorvastatin 80mg — for all ischaemic TIA regardless of cholesterol level
- AF screened — if confirmed: DOAC pathway initiated same day
- Safety-net: BE-FAST symptoms + 999 + written information
- Driving concern named proactively and addressed with empathy — not as an afterthought
- Fear of stroke recurrence directly acknowledged and reassured with risk statistics
- Patient's minimisation ("just a funny turn") addressed with clinical reasoning, not dismissal
- ICE explored and referenced: driving concern → DVLA plan; fear of stroke → risk statistics; expectation of returning to normal → specific timeline
- Closing question asked genuinely and patient given space to express remaining concerns
- Emotional acknowledgement: "this must have been frightening" said at some point
Who you are
Derek Williams, 65-year-old retired teacher. Married, two adult children, four grandchildren he regularly collects from school. Active, independent, proud of his fitness. Has never been on regular medication. Today's BP was 168/98 — he was told his blood pressure was "a bit high" at a pharmacy check 18 months ago but never followed up. Smokes 10/day for 30 years. Drinks 25 units of alcohol per week (3–4 pints most evenings).
Hidden agenda
Derek's primary concern is losing his driving licence — he collects his grandchildren every day and his wife does not drive. A driving ban feels catastrophic. He won't volunteer this unless asked, but if the doctor doesn't raise it he becomes visibly anxious. His secondary hidden agenda is not wanting to take regular tablets — "I've never needed tablets in my life and I don't want to start now." He will resist the medication plan unless the doctor explains the risk in terms he personally relates to (grandchildren, independence).
Symptoms if asked directly
- Right arm suddenly went weak — couldn't lift his cup of tea — lasted about 20 minutes
- Speech slurred — wife said he sounded "drunk" — couldn't get words out properly
- Both symptoms have now completely resolved — he feels "100% fine"
- No headache at onset or now
- No visual changes; no dizziness; no chest pain
- Has had a couple of brief episodes of "heart racing" in the last 6 months lasting a few minutes each — he attributed them to caffeine and never mentioned them to anyone
Lifestyle + bonus details
- Smokes 10/day for 30 years — resistant to stopping ("I'm not a heavy smoker")
- Alcohol: 3–4 pints 5 nights per week — does not consider this excessive
- Not on any medication — paracetamol occasionally
- Drives grandchildren to school every morning — this is central to his identity and routine
- Bonus detail (only if palpitations specifically asked about): he has had episodes of irregular heartbeat lasting 20–30 minutes over the last 6 months — has never reported these
- Father had a stroke at 70 — Derek attributes his episode to "it running in the family" and thinks nothing can be done
Resolution: Derek will accept the plan if the candidate: (1) validates his minimisation before challenging it — not immediately contradicting him; (2) uses the grandchildren specifically as the reason to take this seriously and start treatment ("this is about being there for them"); (3) explains the driving restriction empathetically with a clear return timeline and confirms it's 1 month, not permanent; (4) explores the palpitations if he volunteers them and connects them to the possibility of AF; (5) gives a specific, actionable management plan rather than vague "we need to do some tests." If the doctor is dismissive or fails to address driving, Derek becomes resistant and begins making excuses to leave.
- Symptoms still present (face, arm, speech) → acute stroke → thrombolysis/thrombectomy window
- Thunderclap headache ("worst ever") ± focal neurology → SAH → CT immediately
- Crescendo TIA (≥2 episodes in 7 days) → same-day specialist; admit if ongoing/high-risk
- Posterior fossa signs: ataxia + vomiting + reduced consciousness
- Progressive deficit worsening since onset → large vessel occlusion
- ALL suspected TIA in last 7 days → specialist assessment within 24h (NG128)
- TIA + AF confirmed or suspected → anticoagulation decision same day
- TIA on existing antiplatelet → treatment failure; same-day review
- New carotid bruit + TIA → urgent Doppler; symptomatic 50–99% → CEA ideally within 7 days
- Posterior circulation TIA (diplopia, vertigo, ataxia) → higher risk; same-day
- TIA >7 days ago → aspirin 300mg + specialist assessment within 7 days
- Post-stroke secondary prevention review (BP, lipids, antiplatelet)
- Post-TIA monitoring: targets, PHQ-9, driving update
- Rehabilitation coordination: physio, OT, SALT
| Drug / Target | Test | Timing | Action threshold |
|---|---|---|---|
| Dual antiplatelet (21d) | FBC, U&E | 3 months | Stop aspirin at 21 days; continue clopidogrel. GI bleeding → add PPI; review if significant. |
| DOAC (AF) | U&E + Cockcroft–Gault CrCl | Annually | CrCl <50 → check product-specific dose reduction (rivaroxaban 15 mg if CrCl 15–49; edoxaban 30 mg if 15–50). CrCl <15 → most DOACs contraindicated; haematology. |
| Atorvastatin 80mg | Fasting lipids + LFTs + CK | 3 months; then annually | LDL >2.0 → add ezetimibe. ALT ≥3× ULN → recheck and review; stop if persistent (<3× ULN: continue). CK >5× ULN → stop, repeat after 7 days; >10× with symptoms, weakness, dark urine or renal impairment → urgent rhabdomyolysis assessment. |
| ACEi / Antihypertensive | U&E + eGFR | 2 weeks after start; 3 months | Creatinine rise ≥30% (or eGFR fall ≥25%) → check dehydration and other causes; reduce or stop ACEi if none. K⁺ >6.0 → stop urgently. |
| Post-stroke depression | PHQ-9 | Every review — peaks at 3 months | PHQ-9 ≥10 → NHS Talking Therapies referral; consider an antidepressant if clinically indicated (care with antithrombotics). PHQ-9 ≥20 → urgent psychiatric review. |