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Subject: Transient Ischemic Attack (TIA)
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A transient episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction
Most important predictor of stroke: 7-40% of patients with stroke report previous TIA.
200,000 to 500,000 new TIA cases reported each year
Prevalence of TIA in general population: ~2.3%
Predominant age: risk increases >60 years; highest in 7th and 8th decades
Predominant sex: male > female (3:1)
Predominant race/ethnicity: African Americans > Hispanics > Caucasians. The difference in African Americans is exaggerated at younger ages.
Carotid/vertebral atherosclerotic disease
Small, deep vessel disease associated with HTN
Embolism secondary to the following:
Sympathomimetic drugs (e.g., cocaine)
Other causes: spontaneous and posttraumatic (e.g., chiropractic manipulation) arterial dissection
Cardiac diseases (A-fib, MI, valvular disease)
Atherosclerotic disease (carotid/vertebral stenosis)
Lifestyle changes: smoking cessation, diet modification, weight loss, regular aerobic exercise, and limited alcohol intake
Strict control of medical risk factors: diabetes (glycemic control), HTN (thiazide and/or ACE/ARB), hyperlipidemia (statins), anticoagulation when high risk of cardioembolism (e.g., atrial fibrillation, mechanical valves)
10-20% of patients with TIA have CVA within 90 days; 25-50% of those occur within the first 48 hours.
Older patients have a higher mortality rate than younger patients—highest in 7th and 8th decades.
Atrial fibrillation is a frequent cause among the elderly.
Congenital heart disease is a common cause among pediatric patients.
Other causes include the following:
Preeclampsia, eclampsia, and HELLP
TTP and hemolytic uremic syndrome
Cerebral venous thrombosis
Hypercoagulable states related to pregnancy
Obtain witness accounts with emphasis on symptom onset, progression, and recovery.
Carotid circulation (hemispheric): monocular visual loss, hemiplegia, hemianesthesia, neglect, aphasia, visual field defects (amaurosis fugax); less often, headaches, seizures, amnesia, confusion
Vertebrobasilar (brain stem/cerebellar): bilateral visual obscuration, diplopia, vertigo, ataxia, facial paresis, Horner syndrome, dysphagia, dysarthria; also headache, nausea, vomiting, and ataxia
Past medical history, baseline functional status
ABCD2 score: predicts risk of CVA within 48 hours 1[A]
Vital signs, oxygen saturation
Thorough neurologic and cardiac exams
Focal seizure (Todd paralysis)
Neoplasm of brain
Central nervous system infection
Neuroimaging within 24 hours of symptom onset
MRI, including diffusion-weighted imaging, is the preferred brain diagnostic modality; if not available, then noncontrast head CT 2[B]
Noninvasive imaging of the cervicocephalic vessels should be performed routinely as part of the evaluation of suspected TIA 2[A].
Initial assessment of the extracranial vasculature may involve carotid US/TCD, MRA, or CTA depending on the availability and expertise and characteristics of the patient 2[B].
Routine blood tests (CBC, chemistry, PT/PTT, UPT, and fasting lipid panel) are reasonable in evaluation of patient with TIA 2[B].
If only noninvasive testing is performed prior to CEA, it is reasonable to pursue two concordant noninvasive findings; otherwise, catheter angiography should be considered 2[B].
Echo is reasonable in evaluation of patients with suspected TIA especially when no other cause is noted 2[B].
TEE is useful in identifying PFO, aortic arch atherosclerosis, and valvular disease and is reasonable when this will alter management 2[B].
Prolonged cardiac monitoring is useful in patients with an unclear etiology after initial brain imaging and ECG 2[B].
EEG: if seizure suspected
Consider a sleep study due to the high prevalence of sleep apnea among TIA patients; treatment with CPAP has shown to improve patient outcomes 3[B].
TIA is a neurologic emergency. Immediate medical attention should be sought within 24 hours of symptom onset due to increased stroke risk.
Current evidence suggests that patients with high-risk TIAs require rapid referral and 24-hour admission (ABCD2 score ≥3 g).
Antiplatelet therapy to prevent recurrence or future CVA
Treatment/control of underlying associated conditions
For patients with TIA, the use of antiplatelet agents rather than oral anticoagulation is recommended to reduce risk of recurrent stroke and other cardiovascular events, with the exception of cardioembolic etiologies 2[A].
Uncertain if switching agent in patients who have additional ischemic attacks while on antiplatelet therapy is beneficial 4[C]
Enteric-coated aspirin: 160 to 325 mg/day in the acute phase 5[A] followed by long-term antiplatelet therapy for noncardioembolic TIA and anticoagulation for cardioembolic etiology
Combined aspirin and clopidogrel therapy has been demonstrated to reduce the incidence of subsequent stroke by 21% without increased risk of bleeding when used for a duration of 1 month or less immediately following TIA or CVA 6[A].
For patients who cannot tolerate other agents
Contraindications: hypersensitivity, presence of hematopoietic/hemostatic disorders, conditions associated with bleeding, severe liver dysfunction
Precautions: neutropenia (0.8% severe), which is reversible with cessation of the drug. Monitor blood counts every 2 weeks for first 3 months. TTP can occur.
Significant possible interactions: Digoxin plasma levels decreased 15%; theophylline half-life increased from 8.6 to 12.2 hours.
Neurology for ongoing workup and treatment
Cardiology if cardiac cause suspected
Vascular surgery if carotid endarterectomy appropriate
Secondary prevention of TIA should be initiated; venous thromboembolism (VTE) prophylaxis
Patients with TIA or ischemic stroke should be started on a statin.
BP should be reduced after 24 hours. Thiazides, ACE inhibitors, and ARBs have shown to be of benefit. β-Blockers have not shown benefit in reducing recurrence or stroke.
Patients with DM or pre-DM should be advised to follow ADA guidelines to maintain tight glycemic control 3[A].
Consider carotid endarterectomy in patients with a high degree of carotid artery stenosis ≥70%.
When carotid endarterectomy is indicated for patients with TIA, surgery within 2 weeks is reasonable if there are no contraindications to early revascularization.
ABCD2 score of >3
ABCD2 score of 0 to 3 and uncertainty that dx workup can be completed within 2 days as outpatient. Alternatively: If urgent imaging not available through ED or urgent neurology follow-up not available, admit ABCD2 score ≥3 with evidence of focal ischemia.
Outpatient follow-up with neuro support every 3 months for 1st year then annually
Close attention to recurrent or subsequent CVA
DASH diet or as appropriate for underlying medical problems
The risk of stroke on the ipsilateral side within 90 days and cumulative thereafter is 10-20%.
Frequency increases with the addition of multiple risk factors and severity of carotid stenosis.
Patients with larger artery occlusion or cardioembolic etiology are at increased risk of recurrence.
The major cause of death in the first 5 years is cardiac disease.
Simmons BB, Cirignano B, Gadegbeku AB. Transient ischemic attack: part I. diagnosis and evaluation. Am Fam Physician. 2012;86(6):521–526.
Simmons BB, Gadeqbeku AB, Cirignano B. Transient ischemic attack: part II. risk factor modification and treatment. Am Fam Physician. 2012;86(6):527–532.
G45.9 Transient cerebral ischemic attack, unspecified
G45.1 Carotid artery syndrome (hemispheric)
G45.0 Vertebro-basilar artery syndrome
G45.8 Oth transient cerebral ischemic attacks and related synd
G45.2 Multiple and bilateral precerebral artery syndromes
435.9 Unspecified transient cerebral ischemia
435.1 Vertebral artery syndrome
435.3 Vertebrobasilar artery syndrome
435.8 Other specified transient cerebral ischemias
266257000 Transient ischemic attack (disorder)
230716006 Carotid territory transient ischemic attack
230717002 Vertebrobasilar territory transient ischemic attack (disorder)
426814001 Transient cerebral ischemia due to atrial fibrillation (disorder)
88032003 Amaurosis fugax (disorder)
Stress smoking cessation, exercise, weight loss, limited ETOH intake, and control of HTN, hyperlipidemia, and diabetes
Antiplatelet therapy (e.g., aspirin, clopidogrel, or aspirin-dipyridamole) should be initiated.
Warfarin should be initiated in patients with atrial fibrillation or cardioembolic risk factors.