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Suspected retinal transient ischaemic attack — DFSRH MCQ

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HardAssessmentSuspected retinal transient ischaemic attackDFSRH

A 32-year-old woman attends a sexual and reproductive health clinic for review of her combined oral contraceptive, containing ethinylestradiol 30 micrograms with levonorgestrel. She has used it correctly for 4 months. She has a history of migraine without aura, but no cardiovascular risk factors. Yesterday, she experienced sudden painless loss of vision in the right eye, described as a grey curtain descending across the entire visual field. The deficit was maximal immediately, lasted approximately 4 minutes and resolved completely. She specifically covered each eye during the episode and confirmed that only the right eye was affected. There were no flashing lights, zigzags, sensory symptoms or headache. Neurological examination, visual acuity, pupillary responses and fundoscopy are normal today. She has no aspirin allergy, active bleeding, peptic ulceration or anticoagulant use. She believes the episode was probably migraine and asks to continue her pill. Which is the most appropriate immediate management?

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

Reveal the answer and explanation

Correct answer: B — Stop the combined oral contraceptive, give aspirin 300 mg and arrange immediate specialist TIA assessment

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

This episode should be treated as a suspected retinal transient ischaemic attack rather than migraine aura. The sudden onset, immediate maximal deficit, exclusively negative visual phenomenon, confirmed monocular distribution and duration below 5 minutes are characteristic of amaurosis fugax. Typical migraine aura is fully reversible but develops gradually over at least 5 minutes and lasts 5–60 minutes; visual symptoms affecting only one eye also warrant investigation rather than assumption of uncomplicated aura. NICE recommends immediate aspirin 300 mg, unless contraindicated, and immediate referral for specialist assessment within 24 hours after a suspected TIA. A normal examination after symptom resolution does not reduce this urgency. Estrogen-containing contraception should be stopped: FSRH identifies loss of sensory function as requiring urgent review, and UKMEC classifies a history of cerebrovascular accident, including TIA, as category 4 for combined hormonal contraception. B underestimates the vascular urgency; a 2-week ophthalmology pathway is inappropriate for suspected retinal ischaemia. C is attractive because visual aura may occur without headache, but the temporal profile and monocular curtain-like loss are not typical aura. D exposes her to continued estrogen while a potentially serious arterial event remains unassessed. E is incorrect because NICE recommends aspirin before specialist assessment and advises against routine CT for suspected TIA unless an alternative CT-detectable diagnosis is suspected.

Reference: Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (Updated 13 April 2022) — https://www.nice.org.uk/guidance/ng128/chapter/Recommendations Headaches in over 12s: diagnosis and management (Updated 3 June 2025) — https://www.nice.org.uk/guidance/cg150/chapter/Recommendations UK Medical Eligibility Criteria for Contraceptive Use (2016; PDF updated 2019) — https://www.fsrh.org/Common/Uploaded%20files/Standards-and-Guidance/fsrh-ukmec-full-book-2019.pdf