Stroke is caused by an impaired supply of blood to the brain resulting in loss of brain function, and is one of the major causes of mortality and functional disability in the United Kingdom (UK) [1, 2]. The severity of strokes differ between patients and can be classified as major stroke, minor stroke and transient ischemic attack (TIA), also known as mini-stroke. The term major stroke broadly refers to strokes that result in long-term or permanent neurological symptoms and may result in disability. Minor stroke is a term that is widely used in research but has not been formally defined, however, it refers to strokes with symptoms lasting longer than 24 hours but where symptoms are mild and non-disabling . TIA is defined by stroke-like symptoms typically lasting less than one hour and no evidence of acute infarction . TIA and minor stroke also create a substantial burden on society and affect a huge proportion of the population. In England, approximately 20,000 people have a TIA and 23,375 people have a minor stroke every year .
Fatigue, cognitive and psychological problems after stroke
In addition to functional disability, sequelae following stroke include fatigue, cognitive impairments and psychological impairments, such as anxiety, depression and post-traumatic stress disorder (PTSD) . These impairments are documented in the literature and have a detrimental impact on people’s lives [7–10]. Fatigue is multidimensional and comprises physical, emotional and cognitive elements . Fatigue has been shown to impact on stroke survivors’ rehabilitation and quality of life (QoL)  and is associated with depression , inability to return to work  and increased fatality post-stroke . The burden of fatigue should not be underestimated, for instance one study found 40% of stroke patients reported fatigue as their worst symptom .
Anxiety is universally the most common mental health disorder and is coupled with physical, behavioral and cognitive symptoms . Anxiety and depression frequently occur simultaneously and, in this circumstance, depression is more severe and patients experience higher levels of functional and cognitive impairment . Both major and minor depression have been documented post-stroke and can occur at any time point from the acute stage up to five years post-stroke with an estimated prevalence of 33% . In addition, Ayerbe et al. reported that a high proportion of patients with depression post-stroke at one time point remained depressed . Depression is associated with a poor prognosis, decreased QoL and increased mortality .
PTSD can develop after exposure to a life-threatening medical event and has been documented post-stroke . Research has shown that occurrence of post-stroke PTSD is independent of physical disability . PTSD has detrimental implications and patients with PTSD have been shown to have an increased risk for a worse physical and mental health prognosis and have greater suicidal intention . It is speculated that a poor health prognosis related to PTSD is associated with both biological mechanisms, such as high blood pressure, and behavioral factors, such as non-adherence to medication . Resultant non-adherence to medication may impact on stroke and TIA survivors as this is essential for secondary prevention of stroke. PTSD also adversely affects people’s QoL and normal functioning . Conversely, life-threatening events can also produce a positive psychological change known as post-traumatic growth. McGrath and Linley  reported evidence of sustained positive psychological change after acquired brain injury. However the sample size for this study was small. Furthermore post-traumatic growth following stroke is reported to be inversely correlated with anxiety and depression . This concept is relatively new to stroke research and there is only a small amount of literature available, which to our knowledge has not yet been extended to TIA and minor stroke. Therefore this review will be limited to PTSD.
Cognitive impairment is well documented following stroke and exhibits a wide-range of symptoms including difficulty with memory, reading, writing and number skills, visual impairment and difficulty planning and problem solving. A relationship between cognitive and functional impairment has been reported along with a negative impact on rehabilitative outcomes . Cognitive impairment is associated with depression but the directional relationship is unclear . For the purpose of this review, cognitive impairment will encompass impairments of attention, memory, spatial awareness, perception, apraxia and executive functioning as in accordance with the Royal College of Physicians National Clinical Guidelines for Stroke .
Impairment after TIA and minor stroke
Fatigue, psychological and cognitive impairment have been shown to occur post-stroke in the absence of functional impairment and independent of stroke severity . Although TIA and minor stroke are characterized by short-lasting symptoms, evidence suggests that this cohort experience residual problems. Coutts et al.  found that 15% of a sample of TIA and minor stroke patients were disabled at 90 days as defined by a modified Rankin Scale score ≥ 2. Another study reported TIA patients to have comparable QoL scores to stroke patients in all domains with the exception of social isolation . However, results of this study may be unrepresentative of the true stroke population as stroke patients in rehabilitation hospitals and care homes were excluded. Significant fatigue has been reported in a community population of TIA and minor stroke patients with a prevalence, at six months, of 29% and 56% respectively . Qualitative research of people’s experiences following TIA or minor stroke revealed that people reported a variety of residual symptoms . These included functional impairments, such as limb weakness and numbness; cognitive impairments, such as memory difficulties; slurred speech; emotional issues, such as feeling depressed, confused and more emotional .
Current treatment guidelines relevant to TIA and minor stroke focus on secondary prevention of stroke . However, no consideration is given to psychological or cognitive impacts of TIA or minor stroke and patients are not routinely offered additional rehabilitative support. Untreated fatigue, psychological or cognitive impairment will result in a reduced QoL and affect people’s ability to return to work and social activities.
Considering the diversity and complexity of residual impairments anecdotally described by people following TIA and minor stroke, it is important to conduct a comprehensive systematic review of the literature. This is a necessary step to develop future intervention studies that will inform treatment recommendations and guidelines. This systematic review therefore aims to:
Establish the prevalence of fatigue, anxiety, depression, PTSD and cognitive impairment following a TIA or minor stroke and investigate if this prevalence changes over time.
Explore the impact of TIA and minor stroke on people’s QoL, change in emotions and return to work.
Identify where there are gaps in the understanding of residual problems after TIA and minor stroke.