TIA and Minor Stroke

Medication and surgery for transient ischaemic attack (TIA)

Medication
Treatment after a TIA or minor stroke is aimed at preventing another TIA, or stroke. In addition to suggesting lifestyle changes (see ‘Lifestyle changes’) usually patients are prescribed at least one type of medication:
  • medication to reduce blockages in arteries from blood clots - antiplatelets or anticoagulants,
  • medication to lower blood pressure - antihypertensives, and
  • medication to lower cholesterol levels - statins.
Aspirin is the most common ‘antiplatelet’ medication used to prevent clots forming in arteries, and increasingly, doctors may offer an additional antiplatelet medication to increase protection from further strokes (either dipyridamole or clopidogrel). Warfarin is another common drug that is often prescribed usually where the person has an irregular heart rhythm (Atrial fibrillation), and it reduces blood clots forming in the heart which could break up and then cause reduced blood supply to a part of the brain. People taking warfarin need regular blood tests to check that the dose is right, but there are newer drugs to reduce blood clots such as dabigatran, apixaban and rivaroxaban which do not need any blood tests and they may be used more often in the future. There are a lot of different medications for reducing high blood pressure including ACE inhibitors and calcium channel-blockers, beta-blockers and thiazide diuretics. The doctor will prescribe whichever one best suits the patient’s needs and sometimes it can take a while to get the dose or prescription right. The most common drugs that are prescribed to help lower cholesterol levels are called statins, and as with drugs for blood pressure, there are several available such as atorvastatin, simvastatin and rosuvastatin.
 
Most of the people who were interviewed were prescribed various different drugs as a preventative measure and most people believed that the medication would help to reduce the risk of further stroke or TIA. The majority mentioned aspirin as being one of the primary drugs that they were prescribed, and the dosage varied according to the individual. Some people were already taking aspirin for a different reason but may have had to have the dose adjusted after the TIA or minor stroke. Many people were already taking other drugs which may or may not have had to be reviewed in line with the medication prescribed to prevent further TIA or minor stroke.
Sometimes people took the medication that had been prescribed but only had a vague idea about what it was for, whilst others found it difficult to remember the names and details of their medication. Russell (below) experienced short term memory loss after his minor stroke and so finds it useful to keep a written list and also has the details written in a neck tag so that if he’s taken ill the doctors would know what medication he is on.
Some people felt uncomfortable taking some of the medication they were prescribed because they worried about side effects. George had been prescribed blood pressure medication before he had his TIA and after reading the leaflet about possible side effects he wondered whether these tablets had caused his second TIA.
Several people found that they could not tolerate the medication they had been prescribed because they experienced uncomfortable side effects, and it could sometimes take a while to get the dose right, or to find an alternative drug. One of the risks from taking medication to thin the blood is that there can be uncontrolled bleeding. Ken (above) noticed that if he scratched himself he could find himself ‘dripping blood on the floor’ and Geoff (above) had to stop taking aspirin when he was found to be ’losing blood from his tummy’.
Other side effects that people mentioned included stomach upsets, swelling or muscular problems, depression, feeling the cold and headaches. It could sometimes be difficult to know whether these were a result of taking the medication or not. Often it was possible to avoid the side effect by changing to another version of the same type of medication. Ros (below) felt that although drugs could be helpful, ‘that it’s up to you’ to help them work by making lifestyle changes.
Several people experienced depressive feelings after their TIA or minor stroke. Some were given anti-depressant medication, but not everyone wanted to take this type of medication.
Some people stopped or thought about stopping taking their medication because they weren’t happy with the side effects, or just didn’t feel comfortable taking medication on a long term basis.
Sometimes people who had been prescribed several different drugs found it could be difficult to remember to take them at the right times. (See John above).
Most people we interviewed were satisfied with the treatment they had received and felt relatively confident that the medication they had been prescribed was helping to reduce their risk of further stroke. However, one woman was still waiting for a definite diagnosis some months after her episode, and even though the registrar at A&E had said it was suspected to be a TIA, she wasn’t given any preventative medication.
 
Surgery
 
One of the most common causes of stroke and TIA is a blockage in one of the two large arteries that travel along the front of the neck, delivering blood and oxygen to the brain. These arteries are called the carotid arteries. Ultrasound scans are used to check whether there is a blockage which needs treatment.The main treatment options for severe blockages in the carotid artery are carotid endarterectomy, and carotid angioplasty or stenting.
 
Carotid endarterectomy is an operation to clear the blockages in an artery. The surgeon will make a small incision (cut) in the side of the neck so they can see the carotid artery, which will then be clamped shut. The surgeon will then open up the artery and remove the inner lining along with any debris. It is likely that a graft will then be sewn onto theartery to widen it - most surgeons believe this lowers the risk of a repeat stroke. A graft is a piece of tissue that may be taken from a vein in the thigh, or it may be man-made. When the surgeon is finished theartery will be stitched up, the blood supply restored, and the small cut in the neck sewn up (Stroke Association April 2012).
It is most effective when carried out within two weeks of a stroke or TIA and NICEn- National Institute for Health Care Excellence recommends surgery within 2 weeks (CG68)  “In people who have previously had a stroke or a TIA, their risk of having another stroke or TIA within the next three years is reduced by a third after surgery.” NHS choices 2017.

Carotid angioplasty is carried out under local anaesthetic. A small flexible tube is passed into the carotid artery through an artery in the groin. The tube has a small balloon at the end of it. When the tube reaches the narrowed area, the balloon is inflated. This expands the artery, allowing the blood to flow through it again. The balloon is then removed.
 
Carotid stenting involves the same procedure at first, but once the balloon is inflated, a small wire mesh cylinder called a stent is then inserted to keep the artery open, improving blood flow. The stent will stay there permanently.
Frank was told he had a hole in the heart, which is a known risk factor for TIA. He had no idea he had a hole in his heart until this time. It is unclear how far the risk of having further TIAs is reduced by having surgery to close a hole in the heart, and Frank has decided not to have surgery.

The evidence review Frank describes is from the National Institute for Health and Clinical Excellence (NICE).

Last reviewed June 2017.
Last updated
June 2017.

 

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