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Suspected transient ischaemic attack — MRCEM SBA MCQ

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EasyNeurological emergenciesSuspected transient ischaemic attackMRCEM SBA

A 59-year-old woman attends the emergency department two hours after the sudden onset of right arm weakness and difficulty finding words. Both symptoms resolved completely after 20 minutes, and her neurological examination is now normal. Her blood pressure is 126/78 mmHg and capillary glucose is 5.4 mmol/L. She reports no headache, seizure or head injury. She takes no anticoagulant and has no aspirin allergy or history of gastrointestinal bleeding. 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 — Start aspirin 300 mg immediately; arrange specialist assessment within 24 hours of symptom onset.

The abrupt focal weakness and language disturbance, followed by complete resolution, make a transient ischaemic attack (TIA) the working diagnosis. Hypoglycaemia has been excluded. NICE recommends aspirin 300 mg immediately for suspected TIA unless contraindicated, with immediate referral for specialist assessment and investigation **within 24 hours of symptom onset**. Neither symptom resolution nor a potentially low ABCD2 score justifies delaying that assessment. ([nice.org.uk](https://www.nice.org.uk/guidance/ng128/chapter/Recommendations)) B is tempting because brain imaging precedes antiplatelet treatment in some acute stroke pathways. For suspected TIA, however, NICE does not recommend routine CT unless a CT-detectable alternative diagnosis is clinically suspected; this history supplies no such indicator. C incorrectly uses ABCD2 to reduce referral urgency. D substitutes clopidogrel despite no stated contraindication to the recommended immediate aspirin. E delays aspirin for MRI, whereas MRI is considered after specialist assessment when it would help establish the vascular territory or detect another pathology. If MRI is undertaken, NICE advises performing it on the day of that assessment. ([nice.org.uk](https://www.nice.org.uk/guidance/ng128/chapter/Recommendations))

Reference: Stroke and transient ischaemic attack in over 16s: diagnosis and initial management, recommendations 1.1.2 and 1.1.4–1.1.6 (13 April 2022) — https://www.nice.org.uk/guidance/ng128/chapter/Recommendations Stroke and transient ischaemic attack in over 16s: diagnosis and initial management, recommendations 1.2.1–1.2.2 (13 April 2022) — https://www.nice.org.uk/guidance/ng128/chapter/Recommendations