Transient ischemic attack: Difference between revisions

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**Should be viewed as analogous to unstable angina  
**Should be viewed as analogous to unstable angina  
*'''Classic Definition:'''  A sudden, focal neurologic deficit that lasts for less than 24 hours, is presumed to be of vascular origin, and is confined to an area of the brain or eye perfused by a specific artery<ref name="Albers"></ref>
*'''Classic Definition:'''  A sudden, focal neurologic deficit that lasts for less than 24 hours, is presumed to be of vascular origin, and is confined to an area of the brain or eye perfused by a specific artery<ref name="Albers"></ref>
===ABCD2 Score<ref>Johnston SC, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack.Lancet. 2007; 369(9558):283-92.</ref>===
*Risk of stroke at 2d, 7d, and 90d from TIA
*Although prognostic, evidence-based admission thresholds have not been determined
*Score
**Age >60yr (1 pt)
**BP (SBP >140 OR diastolic >90) (1 pt)
**Clinical Features
***Isolated speech disturbance (1 pt)
***Unilateral weakness (2 pts)
**Duration of symptoms
***10-59 min (1 pt)
***>60 min (2 pts)
**DM (1 pt)
{| class="wikitable"
|-
| '''Points<br>'''
| '''Stroke 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>
|}
None with score <3 had CVA within one week in study


==Causes==
==Causes==

Revision as of 13:56, 28 September 2015

Background

  • Abbreviation: TIA
  • New Definition: a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction. [1]
    • Should be viewed as analogous to unstable angina
  • Classic Definition: A sudden, focal neurologic deficit that lasts for less than 24 hours, is presumed to be of vascular origin, and is confined to an area of the brain or eye perfused by a specific artery[1]

Causes

Differential Diagnosis

Stroke-like Symptoms

Diagnosis

Stroke Work-Up

  • Labs
    • POC glucose
    • CBC
    • Chemistry
    • Coags
    • Troponin
    • T&S
  • ECG
    • In large ICH or stroke, may see deep TWI and prolong QT, occ ST changes
  • Head CT (non-contrast)
    • In ischemia stroke CT has sensitivity 42%, specificity 91%[2]
    • In acute ICH the sensitivity is 95-100%[3]
    • The goal of CTH is to identify stroke mimics (ICH, mass lesions, etc .)[4]
  • Also consider:
    • CTA brain and neck
      • To check for large vessel occlusion for potential thrombectomy
      • Determine if there is carotid stenosis that warrants endarterectomy urgently
    • Pregnancy test
    • CXR (if infection suspected)
    • UA (if infection suspected)
    • Utox (if ingestion suspected)

MR Imaging (for Rule-Out CVA or TIA)

  • MRI Brain with DWI, ADC (without contrast) AND
  • Cervical vascular imaging (ACEP Level B in patients with high short-term risk for stroke):[5]
    • MRA brain (without contrast) AND
    • MRA neck (without contrast)
      • May instead use Carotid CTA or US (Carotid US slightly less sensitive than MRA)[6] (ACEP Level C)

Disposition

AHA/ASA Guidelines[7]

  • Reasonable to hospitalize pts w/ TIA who present w/in 72 hr of symptom onset and have:
    • ABCD2 score of ≥ 3
    • ABCD2 score of 0-2 and uncertainty that diagnostic w/u can be completed w/in 2d as oupt
    • ABCD2 score of 0-2 and other evidence that event was caused by focal ischemia

NSA Guidelines[8]

  • Hospitalization for pts with first TIA w/in past 24-48hr
  • Recommended admission for pts w/ the following:
    • Crescendo TIA (more than three TIAs in 72hr period)
    • Duration of symptoms >1hr
    • Symptomatic carotid stenosis >50%
    • Known cardiac source of embolus
    • Known hypercoaguable state
    • High risk of early stroke after TIA

External Links

MDCalc ABCD2 Score

See Also

References

  1. ↑ 1.0 1.1 Albers GW, et al. The TIA Working Group. Transient ischemic attack: proposal for a new definition. N Engl J Med. 2002; 347:1713–1716.
  2. ↑ Mullins ME, Schaefer PW, Sorensen AG, Halpern EF, Ay H, He J, Koroshetz WJ, Gonzalez RG. CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department. Radiology. 2002 Aug;224(2):353-60.
  3. ↑ Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006; 354(4):387–396.
  4. ↑ Douglas VC, Johnston CM, Elkins J, et al. Head computed tomography findings predict short-term stroke risk after transient ischemic attack. Stroke. 2003;34:2894-2899.
  5. ↑ ACEP Clinical Policy: Suspected Transient Ischemic Attack full text
  6. ↑ Nederkoorn PJ, Mali WP, Eikelboom BC, et al. Preoperative diagnosis of carotid artery stenosis. Accuracy of noninvasive testing. Stroke. 2002;33:2003-2008.
  7. ↑ Easton JD, et al. Definition and evaluation of transient ischemic attack. A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. Stroke. 2009; 40:2276-2293.
  8. ↑ Johnston SC, et al. National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol. 2006; 60(3):301-13.
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