Intended for healthcare professionals

Endgames Case report

An episode of transient neurological symptoms

BMJ 2009; 338 doi: (Published 26 February 2009) Cite this as: BMJ 2009;338:b616
  1. Colin B Josephson, neurology resident1,
  2. Rustam Al-Shahi Salman, MRC clinician scientist and honorary consultant neurologist2,
  3. Stephen J Phillips, professor of medicine (neurology)1
  1. 1Department of Medicine, Division of Neurology, Dalhousie University, Halifax, NS, Canada B3H 3A7
  2. 2Division of Clinical Neurosciences, University of Edinburgh, Edinburgh
  1. Correspondence to: S J Phillips stephen.phillips{at}

    A 72 year old, right handed man presented with weakness of the right hand and difficulty expressing himself, although he was able to comprehend those around him. The symptoms were maximal at onset and resolved spontaneously within one hour. He had a history of hypertension and type 2 diabetes mellitus. His only drugs were metformin and a thiazide diuretic. His neurological and general examinations were normal, and his blood pressure was 140/90 mm Hg. Computed tomography of his brain was normal.


    • 1 What is the diagnosis?

    • 2 Where is the lesion, and how might you confirm the diagnosis?

    • 3 What are the immediate goals in evaluation and treatment?


    Short answers

    • 1 Transient ischaemic attack (TIA).

    • 2 Expressive aphasia and right hand weakness localise to the middle cerebral artery territory of the left hemisphere. The diagnosis of a TIA is usually made on the basis of the patient’s history. A relevant hyperintense lesion on the diffusion weighted magnetic resonance imaging (MRI) sequence and a corresponding hypointense lesion on the apparent diffusion coefficient MRI sequence, which indicates ischaemia, can be seen in less than half of patients.

    • 3 Perform a thorough history and physical examination, consider conditions that mimic TIA, and seek an underlying cause of the TIA. The ABCD2 score helps to estimate …

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