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Suspected transient ischaemic attack — MSRA MCQ

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HardMRISuspected transient ischaemic attackMSRA

A 58-year-old man is assessed urgently in general practice 2 hours after a 12-minute episode of sudden inability to find words and weakness of his right arm. Symptoms began simultaneously while reading, were entirely negative phenomena, and resolved fully before he arrived. He had no headache, seizure activity, loss of awareness, visual disturbance, chest pain or palpitations. He has treated hypertension and hypercholesterolaemia but no diabetes or previous stroke. Capillary glucose is normal. Blood pressure is 136/82 mmHg, ECG shows sinus rhythm, and neurological examination is normal. His ABCD2 score is 3. There is no clinical suspicion of head injury, intracranial infection, tumour, subdural haematoma or another alternative diagnosis detectable on CT. Which is the most appropriate immediate imaging and referral plan?

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

Reveal the answer and explanation

Correct answer: B — Arrange immediate specialist TIA assessment within 24 hours without primary-care CT or MRI; consider same-day MRI after specialist assessment

Explanation lettering: B = shown as A · D = shown as B · E = shown as D · A = shown as E

This is a suspected TIA: there was abrupt onset of focal, negative cortical symptoms (dysphasia and unilateral arm weakness), with complete resolution and no persuasive feature of a mimic. All suspected TIAs require immediate specialist assessment, to occur within 24 hours of symptom onset; ABCD2 must not be used to reduce referral urgency. In the absence of clinical suspicion of an alternative structural diagnosis, CT brain should not be requested routinely for suspected TIA. MRI is not a primary-care prerequisite for referral. Following specialist TIA assessment, MRI incorporating diffusion-weighted and blood-sensitive sequences may be considered on the same day to define an ischaemic territory or identify haemorrhage or alternative pathology. A is incorrect because routine CT is not indicated in uncomplicated suspected TIA. B is attractive because diffusion-weighted MRI can support the diagnosis, but it should not delay specialist assessment or be arranged as a pre-referral requirement. C both delays urgent assessment and unnecessarily specifies contrast MRI. E incorrectly applies a low ABCD2 score to defer review; NICE advises against using such scores to determine referral urgency.

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