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  1. Martin M Brown
  1. Professor Martin M Brown, Department of Clinical Neurology, Institute of Neurology, Queen Square, London WC1N 3BG, UK m.brown{at}

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Usually, difficulty in the diagnosis and management of stroke occurs because of the rarity of the presentation, ignorance about the condition, or the lack of scientific clinical trial data to support clinical decisions. This article focuses on a very individual selection of topics, with much of the advice concerning management representing a personal view. It is not intended to be comprehensive, and is limited mainly to transient ischaemic attack (TIA) and ischaemic stroke.

The importance of retaking a detailed history from the patient and their carers or friends in difficult cases cannot be overemphasised. Radiological investigations should be reviewed, taking the history into account, and remembering that minor vascular abnormalities are common in the elderly and that optimum sequences may not have been used, particular with magnetic resonance imaging (MRI). More extensive investigation may be required.

Differential diagnosis of transient symptoms

The difficulty of diagnosing TIA is illustrated by the wide variety of diagnoses made in patients referred to vascular clinics (table 1).1 The sudden onset of neurological symptoms is a useful criterion for the diagnosis of TIA. Most recover within 10–30 minutes. As a general principle, the syndromes of TIA will mimic those of stroke, since the symptoms are a function of the vascular territory of the occluded artery or arteriole. Thus isolated dizziness or vertigo, or loss of consciousness, are unlikely to be TIAs, whereas pure unilateral motor weakness—provided it involves at least two of face, arm or leg—can be clearly recognised as a lacunar TIA. The symptoms of most TIAs are loss of function, such as aphasia, weakness or numbness, as opposed to positive symptoms such as tingling or involuntary movements, which are more likely to have a non-ischaemic cause.

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Table 1

Final diagnosis in 211 new patients referred to a cerebrovascular disease clinic.1

Haemodynamic TIAs are an important exception. These …

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