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Suspected transient ischaemic attack — MSRA MCQ

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HardMRISuspected transient ischaemic attackMSRA

A 71-year-old man presents to his GP at 09:15 after a 20-minute episode of sudden right arm weakness and difficulty producing words while eating breakfast at 08:05. His symptoms resolved completely before arrival. He has hypertension and hypercholesterolaemia. He has no headache, head injury, seizure activity, loss of consciousness, fever or recurrent stereotyped episodes. He does not take anticoagulants or antiplatelets and has no history of gastrointestinal bleeding or aspirin allergy. Capillary blood glucose is 6.0 mmol/L. Neurological examination is now normal. What is the most appropriate immediate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Give aspirin 300 mg immediately, refer immediately for specialist TIA assessment within 24 hours, and consider same-day MRI with diffusion-weighted and blood-sensitive sequences after specialist assessment.

This is a suspected anterior-circulation TIA: there was abrupt focal negative neurological dysfunction (right arm weakness and expressive language disturbance), complete resolution, normal glucose and no persisting deficit. NICE recommends immediate aspirin 300 mg unless contraindicated and immediate specialist assessment, with the person seen within 24 hours of symptom onset. ABCD2-based delay is not recommended. Routine CT is not indicated for a clinically straightforward suspected TIA. CT is reserved where an alternative diagnosis detectable by CT is suspected, for example intracranial haemorrhage or a mass lesion. This patient has no severe headache, head injury, anticoagulant treatment, impaired consciousness or persisting/progressive deficit to suggest an acute-stroke or alternative-pathology CT pathway. MRI is not a prerequisite to referral and should not delay specialist assessment. Following assessment in the TIA clinic, MRI may be considered to define the ischaemic territory or identify haemorrhage or an alternative pathology; if undertaken, it should occur on the same day and include diffusion-weighted and blood-sensitive sequences. Carotid imaging is subsequently indicated for people whom the specialist considers potential candidates for carotid endarterectomy, rather than as a GP-led gatekeeper test.

Reference: NICE NG128: Stroke and transient ischaemic attack in over 16s: diagnosis and initial management — Recommendations (2019; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng128/chapter/recommendations