Transient ischemic attack: Difference between revisions
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==Definition==
== Definition ==


"Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without infarction.” Stroke 2009;40[6]:2276
"Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without infarction.” Stroke 2009;40[6]:2276


==Background==
== Background ==


1. Ischemic
#Ischemic
* Thrombosis
##Thrombosis
* Vasculitis
##Vasculitis
* Dissection
##Dissection
2. Embolic
#Embolic
* Cardiac
##Cardiac
* Carotids
##Carotids
3. Vasospasm
#Vasospasm
#Hypotension (watershed)


4. Hypotension (watershed)
== DDx ==


==DDx==
#Hypoglycemia
* Hypoglycemia
#Infectious endocarditis
* Infectious endocarditis
#Complex migraines
* Complex migraines
#Peripheral cranial nerve lesions
* Peripheral cranial nerve lesions
#Seizure
* Seizure


==Work-Up==
== Work-Up ==


* Head CT
#Head CT
* Labs
#Labs
** CBC (thrombocytosis)
##CBC (thrombocytosis)
** Chemistry (hyponatremia)
##Chemistry (hyponatremia)
** Coags
##Coags
* ECG (a-fib)
#ECG (a-fib)
* CXR
#CXR
* ?MRI/MRA or ?Neuro labs (ESR?, lipids?)
# ?MRI/MRA or ?Neuro labs (ESR?, lipids?)


==Treatment==
== Treatment ==


* Head of bed lowered
#Head of bed lowered
* Permissive hypertension
#Permissive hypertension
* NS 500cc bolus, then 150cc/hr (non-CHF/fluid overloaded)
#NS 500cc bolus, then 150cc/hr (non-CHF/fluid overloaded)
* ASA
#ASA
* Heparin if cardiac embolic source/a-fib (usually different vascular territories)
#Heparin if cardiac embolic source/a-fib (usually different vascular territories)


==Disposition==
== Disposition ==


AHA/ASA guidelines: Reasonable to hospitalize patients with TIA who present w/in 72 hr of symptom onset and meet any of the following criteria:
AHA/ASA guidelines: Reasonable to hospitalize patients with TIA who present w/in 72 hr of symptom onset and meet any of the following criteria:


1. ABCD2 score of ≥ 3
#ABCD2 score of ≥ 3
#ABCD2 score of 0-2 and uncertainty that the diagnostic workup can be completed within two days as an outpatient
#ABCD2 score of 0-2 and other evidence that the event was caused by focal ischemia


2. ABCD2 score of 0-2 and uncertainty that the diagnostic workup can be completed within two days as an outpatient
=== ABCD2 SCORE ===


3. ABCD2 score of 0-2 and other evidence that the event was caused by focal ischemia
*Age > 60 (1 pt)
*Blood pressure (SBP >140 OR diastolic >90) (1 pt)
*Clinical Features
**unilateral weakness (2 pt)
**isolated speech disturbance (1 pt)
*Duration of symptoms
**>60 min (2 pt)
**10-59 min (1 pt)
*Diabetes (1 pt)


ABCD2 SCORE
{| style="width: 500px" border="1" cellpadding="1" cellspacing="1"
|-
| '''Points<br/>'''
| '''Risk<br/>'''
| '''Two Days<br/>'''
| '''Seven Days <br/>'''
| '''90 Days<br/>'''
|-
| 0-3<br/>
| Low<br/>
| 1.0%<br/>
| 1.2%<br/>
| 3.1%<br/>
|-
| 4-5<br/>
| Moderate<br/>
| 4.1%<br/>
| 5.9%<br/>
| 9.8%<br/>
|-
| 6-7<br/>
| High<br/>
| 8.1%<br/>
| 11.7%<br/>
| 17.8%<br/>
|}


Age > 60 (1 pt)
None with score < 3 had CVA within one week in study
Blood pressure (SBP >140 OR diastolic >90) (1 pt)
Clinical Features
* unilateral weakness (2 pt)
* isolated speech disturbance (1 pt)
Duration of symptoms
* >60 min (2 pt)
* 10-59 min (1 pt)
Diabetes (1 pt)
* None with score < 3 had CVA within one week in study


National Stroke Association reccomends hospitalization be considered for pts with first TIA w/in past 24-48 hours, and is generally recommended for pts with the following conditions:
National Stroke Association reccomends hospitalization be considered for pts with first TIA w/in past 24-48 hours, and is generally recommended for pts with the following conditions:


* Crescendo TIA
#Crescendo TIA
* Duration of symptoms > 1hr
#Duration of symptoms > 1hr
* Symptomatic carotid stenosis > 50%
#Symptomatic carotid stenosis > 50%
* Known cardiac source of embolus
#Known cardiac source of embolus
* Known hypercoaguable state
#Known hypercoaguable state
* High risk of early stroke after TIA
#High risk of early stroke after TIA
 
Literature:
 
Johnston, SC et al.  JAMA.  Dec 13, 2000.
 
    To determine which pts need to be admitted vs rapid outpatient evaluation.
 
    10% of pts with TIA developed CVA within 90 days.
 
    50% (5%) within 2 days.
 
 
Kaiser Study
 
    Greater risk of CVA (admit any)
 
1.  Age >60
 
2.  DM
 
3.  Duration >10min
 
4.  Motor weakness
 
5.  Speech impairment (dysarthria/ aphasia)
 
 
Numbness is low risk:  outpt f/u with Neuro
 
(also, at increased risk of CVA if >4 TIA spells within last 2 wks, or escalating / crescendo TIA)
 
Transient monocular blindness (amaurosis fugax) more benign.
 
 
 
in Mayo Clinic Proceedings, Nov 1994.  33% of pts with TIA will have CVA within 5 yrs.
 
    high risk... inpt w/u
 
    low risk... expedited outpt w/u
 
    ECG for a-fib
 
    Echocardiogram, TEE most sensitive.  prosthetic valves... DCM... mural thrombosis, SBE, post-MI.
 
    Carotid duplex, if +, cerebral angiogram, then CEA.
 
    ----ASA
 
    ----Heparin if cardiac embolic source/a-fib.  usually different vascular territories.
 
    ----if ASA intolerant or ASA failure, then Ticlopidine.  consider Coumadin.
 
    or,        Plavix alone. 
 


TIA ADMIT (nmlly neg sy; <1hr)
TIA ADMIT (nmlly neg sy; <1hr)
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2) <1 wk from onset
2) <1 wk from onset


==Source==
== Source ==
 


DONALDSON (Smith, Lampe, NEJM '07, Pani)
DONALDSON (Smith, Lampe, NEJM '07, Pani)


[[Category:Neuro]]
[[Category:Neuro]]

Revision as of 08:22, 28 March 2011

Definition

"Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without infarction.” Stroke 2009;40[6]:2276

Background

  1. Ischemic
    1. Thrombosis
    2. Vasculitis
    3. Dissection
  2. Embolic
    1. Cardiac
    2. Carotids
  3. Vasospasm
  4. Hypotension (watershed)

DDx

  1. Hypoglycemia
  2. Infectious endocarditis
  3. Complex migraines
  4. Peripheral cranial nerve lesions
  5. Seizure

Work-Up

  1. Head CT
  2. Labs
    1. CBC (thrombocytosis)
    2. Chemistry (hyponatremia)
    3. Coags
  3. ECG (a-fib)
  4. CXR
  5.  ?MRI/MRA or ?Neuro labs (ESR?, lipids?)

Treatment

  1. Head of bed lowered
  2. Permissive hypertension
  3. NS 500cc bolus, then 150cc/hr (non-CHF/fluid overloaded)
  4. ASA
  5. Heparin if cardiac embolic source/a-fib (usually different vascular territories)

Disposition

AHA/ASA guidelines: Reasonable to hospitalize patients with TIA who present w/in 72 hr of symptom onset and meet any of the following criteria:

  1. ABCD2 score of ≥ 3
  2. ABCD2 score of 0-2 and uncertainty that the diagnostic workup can be completed within two days as an outpatient
  3. ABCD2 score of 0-2 and other evidence that the event was caused by focal ischemia

ABCD2 SCORE

  • Age > 60 (1 pt)
  • Blood pressure (SBP >140 OR diastolic >90) (1 pt)
  • Clinical Features
    • unilateral weakness (2 pt)
    • isolated speech disturbance (1 pt)
  • Duration of symptoms
    • >60 min (2 pt)
    • 10-59 min (1 pt)
  • Diabetes (1 pt)
Points
 		Risk
 		Two Days
 		Seven Days
90 Days
0-3
 Low
 1.0%
 1.2%
 3.1%
4-5
 Moderate
 4.1%
 5.9%
 9.8%
6-7
 High
 8.1%
 11.7%
 17.8%

None with score < 3 had CVA within one week in study

National Stroke Association reccomends hospitalization be considered for pts with first TIA w/in past 24-48 hours, and is generally recommended for pts with the following conditions:

  1. Crescendo TIA
  2. Duration of symptoms > 1hr
  3. Symptomatic carotid stenosis > 50%
  4. Known cardiac source of embolus
  5. Known hypercoaguable state
  6. High risk of early stroke after TIA

TIA ADMIT (nmlly neg sy; <1hr)

1) any Johnson criteria

2) <1 wk from onset

Source

DONALDSON (Smith, Lampe, NEJM '07, Pani)

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