Transient ischemic attack: Difference between revisions
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== Background == | ==Background== | ||
*Definition: | *Abbreviation: TIA | ||
*Should be viewed as analogous to unstable angina | *'''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. <ref name="Albers">Albers GW, et al. The TIA Working Group. Transient ischemic attack: proposal for a new definition. N Engl J Med. 2002; 347:1713–1716.</ref> | ||
**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> | |||
*Since 15% of strokes are preceded by TIA, timely eval of high risk conditions like [[Atrial Fibrillation]] and [[Carotid stenosis|Carotid Stenosis]] is important | |||
===ABCD2 Score=== | ==Clinical Features== | ||
*Focal weakness (Paralysis or paresis of the face, arm, or leg and typically unilateral) | |||
*Dysarthria or dysphasia or aphasia | |||
*Vision changes (Field deficits, blindness, or diplopia) | |||
*Changes in balance or coordination | |||
==Differential Diagnosis== | |||
{{Stroke DDX}} | |||
==Evaluation== | |||
{{Stroke workup}} | |||
==Management== | |||
*Little acute management (given normally resolution of symptoms) | |||
*Consider [[aspirin]] (once hemorrhage ruled-out) | |||
*Consider dual antiplatelet therapy for high risk TIAs<ref>Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, Kim AS, Lindblad AS, Palesch YY. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med. 2018 Jul 19;379(3):215-225.</ref> | |||
**Load with ASA 325 mg chewed, followed by ASA 81 mg PO daily | |||
**Load with [[clopidogrel]] 300 mg PO followed by 75 mg daily for 3 weeks only | |||
==Disposition== | |||
===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 | *Risk of stroke at 2d, 7d, and 90d from TIA | ||
*Although prognostic, evidence-based admission thresholds have not been determined | *Although prognostic, evidence-based admission thresholds have not been determined | ||
* | *None with score <3 had CVA within one week in study | ||
* | *Studies have failed to validate the ABCD2 score, and may cause physicians to incorrectly classify ~8% of patients as low risk, with sensitivity of the score for high risk patients only ~30%<ref>Stead LG, Suravaram S. An assessment of the incremental value of the ABCD2 score in the emergency department evaluation of transient ischemic attack. Ann Emerg Med. 2011 Jan;57(1):46-51.</ref><ref>Ghia D, Thomas P. Low positive predictive value of the ABCD2 score in emergency department transient ischaemic attack diagnoses: the South Western Sydney transient ischaemic attack study. Intern Med J. 2012 Aug;42(8):913-8.</ref> | ||
'''Scoring''' | |||
*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) | |||
*[[Diabetes mellitus]] (1 pt) | |||
{| | {| class="wikitable" | ||
|- | |- | ||
| '''Points | | '''Points''' | ||
| '''Stroke Risk | | '''Stroke Risk''' | ||
| '''Two Days | | '''Two Days''' | ||
| '''Seven Days | | '''Seven Days''' | ||
| '''90 Days | | '''90 Days''' | ||
|- | |- | ||
| 0-3 | | 0-3 | ||
| Low | | Low | ||
| 1.0% | | 1.0% | ||
| 1.2% | | 1.2% | ||
| 3.1% | | 3.1% | ||
|- | |- | ||
| 4-5 | | 4-5 | ||
| Moderate | | Moderate | ||
| 4.1% | | 4.1% | ||
| 5.9% | | 5.9% | ||
| 9.8% | | 9.8% | ||
|- | |- | ||
| 6-7 | | 6-7 | ||
| High | | High | ||
| 8.1% | | 8.1% | ||
| 11.7% | | 11.7% | ||
| 17.8% | | 17.8% | ||
|} | |} | ||
*According to the 2018 Canadian Heart and Stroke Guideline, the '''Clinical''' component of the ABCD2 score is the most important prognostic feature<ref>Boulanger JM, Lindsay MP, Gubitz G, et al. Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. Int J Stroke. 2018;:1747493018786616.</ref> | |||
**Very high risk for recurrent stroke are the following symptoms that have occurred within the last 48 hours | |||
***Transient, fluctuating or persistent unilateral weakness (face, arm and/or leg) | |||
***Transient, fluctuating or persistent language/speech disturbance | |||
***And/or fluctuating or persistent symptoms without motor weakness or language/speech disturbance | |||
===AHA/ASA Guidelines<ref>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.</ref>=== | |||
*Reasonable to hospitalize patients with TIA who present within 72 hr of symptom onset and have: | |||
=== AHA/ASA Guidelines<ref>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.</ref> === | |||
*Reasonable to hospitalize | |||
**ABCD2 score of ≥ 3 | **ABCD2 score of ≥ 3 | ||
**ABCD2 score of 0-2 and uncertainty that diagnostic | **ABCD2 score of 0-2 and uncertainty that diagnostic workup can be completed within 2d as outpatient | ||
**ABCD2 score of 0-2 and other evidence that event was caused by focal ischemia | **ABCD2 score of 0-2 and other evidence that event was caused by focal ischemia | ||
=== NSA Guidelines === | ===NSA Guidelines<ref>Johnston SC, et al. National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol. 2006; 60(3):301-13.</ref>=== | ||
*Hospitalization for | *Hospitalization for patients with first TIA within past 24-48hr | ||
*Recommended admission for | *Recommended admission for patients with the following: | ||
**Crescendo TIA (more than three TIAs in 72hr period) | **Crescendo TIA (more than three TIAs in 72hr period) | ||
**Duration of symptoms >1hr | **Duration of symptoms >1hr | ||
Line 80: | Line 92: | ||
**High risk of early stroke after TIA | **High risk of early stroke after TIA | ||
== See Also == | ===ACEP Guidelines<ref name="ACEP">ACEP Clinical Policy: Suspected Transient Ischemic Attack[https://www.acep.org/Physician-Resources/Policies/Clinical-policies/Clinical-Policy-Suspected-Transient-Ischemic-Attack/ full text]</ref>=== | ||
*Level B: In adult patients with suspected TIA, do not rely on current existing risk stratification instruments (eg, age, blood pressure, clinical features, duration of TIA and presence of diabetes [ABCD2] score) to identify TIA patients who can be safely discharged from the ED. | |||
**In contrast to the 2009 AHA/ASA recommendations that were based on limited research, the ABCD2 does not sufficiently identify the short-term risk for stroke to use alone as a risk-stratification instrument. | |||
**Multiple other risk-stratification instruments have been evaluated less frequently than the ABCD2 score. None have demonstrated the ability to identify individual patients at sufficiently low short-term risk for stroke to use alone as a risk-stratification instrument. | |||
*Level B: A rapid ED based diagnostic protocol can be used to safely identify patients at short-term risk for stroke. | |||
**Study based on observation units and outpatient TIA clinics<ref>Ross MA, Compton S, Medado P, et al. An emergency department diagnostic protocol for patients with transient ischemic attack: a randomized controlled trial. Ann Emerg Med. 2007;50:109-119</ref> | |||
[[File:TIA ADP.png|thumbnail|Example of a rapid ED protocol for TIA]] | |||
===Urgent Cardiac Workup=== | |||
*Urgent echocardiogram and/or holter monitor may be needed to identify patients requiring conditions requiring anticoagulation (such as atrial fibrillation not seen during ED workup) | |||
*Two groups that may require inpatient or urgent outpatient workup | |||
**Known heart disease including [[CHF]], severe valvular disease, severe CAD, history of MI, rheumatic heart disease | |||
**Patients with no clear cause of TIA and no classic risk factors (such as paroxysmal atrial fibrillation, severe valvular disease, PFO) | |||
==External Links== | |||
[http://www.mdcalc.com/abcd2-score-for-tia/ MDCalc ABCD2 Score] | |||
==See Also== | |||
*[[CVA (Main)]] | *[[CVA (Main)]] | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Neurology]] |
Revision as of 06:31, 19 February 2019
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]
- Since 15% of strokes are preceded by TIA, timely eval of high risk conditions like Atrial Fibrillation and Carotid Stenosis is important
Clinical Features
- Focal weakness (Paralysis or paresis of the face, arm, or leg and typically unilateral)
- Dysarthria or dysphasia or aphasia
- Vision changes (Field deficits, blindness, or diplopia)
- Changes in balance or coordination
Differential Diagnosis
Stroke-like Symptoms
- Stroke
- Seizures/postictal paralysis (Todd paralysis)
- Syncope
- Subdural hemorrhage
- Epidural hemorrhage
- Hypoglycemia
- Hyponatremia
- Meningitis/encephalitis
- Hyperosmotic Coma
- Labyrinthitis
- Drug toxicity
- Bell's Palsy
- Complicated migraine
- Meniere Disease
- Demyelinating disease (MS)
- Conversion disorder
- Transient global amnesia
- Giant cell arteritis
- Cerebral sinus thrombosis
Evaluation
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)
- Also consider:
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)
Management
- Little acute management (given normally resolution of symptoms)
- Consider aspirin (once hemorrhage ruled-out)
- Consider dual antiplatelet therapy for high risk TIAs[7]
- Load with ASA 325 mg chewed, followed by ASA 81 mg PO daily
- Load with clopidogrel 300 mg PO followed by 75 mg daily for 3 weeks only
Disposition
ABCD2 Score[8]
- Risk of stroke at 2d, 7d, and 90d from TIA
- Although prognostic, evidence-based admission thresholds have not been determined
- None with score <3 had CVA within one week in study
- Studies have failed to validate the ABCD2 score, and may cause physicians to incorrectly classify ~8% of patients as low risk, with sensitivity of the score for high risk patients only ~30%[9][10]
Scoring
- 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)
- Diabetes mellitus (1 pt)
Points | Stroke 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% |
- According to the 2018 Canadian Heart and Stroke Guideline, the Clinical component of the ABCD2 score is the most important prognostic feature[11]
- Very high risk for recurrent stroke are the following symptoms that have occurred within the last 48 hours
- Transient, fluctuating or persistent unilateral weakness (face, arm and/or leg)
- Transient, fluctuating or persistent language/speech disturbance
- And/or fluctuating or persistent symptoms without motor weakness or language/speech disturbance
- Very high risk for recurrent stroke are the following symptoms that have occurred within the last 48 hours
AHA/ASA Guidelines[12]
- Reasonable to hospitalize patients with TIA who present within 72 hr of symptom onset and have:
- ABCD2 score of ≥ 3
- ABCD2 score of 0-2 and uncertainty that diagnostic workup can be completed within 2d as outpatient
- ABCD2 score of 0-2 and other evidence that event was caused by focal ischemia
NSA Guidelines[13]
- Hospitalization for patients with first TIA within past 24-48hr
- Recommended admission for patients with 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
ACEP Guidelines[5]
- Level B: In adult patients with suspected TIA, do not rely on current existing risk stratification instruments (eg, age, blood pressure, clinical features, duration of TIA and presence of diabetes [ABCD2] score) to identify TIA patients who can be safely discharged from the ED.
- In contrast to the 2009 AHA/ASA recommendations that were based on limited research, the ABCD2 does not sufficiently identify the short-term risk for stroke to use alone as a risk-stratification instrument.
- Multiple other risk-stratification instruments have been evaluated less frequently than the ABCD2 score. None have demonstrated the ability to identify individual patients at sufficiently low short-term risk for stroke to use alone as a risk-stratification instrument.
- Level B: A rapid ED based diagnostic protocol can be used to safely identify patients at short-term risk for stroke.
- Study based on observation units and outpatient TIA clinics[14]
Urgent Cardiac Workup
- Urgent echocardiogram and/or holter monitor may be needed to identify patients requiring conditions requiring anticoagulation (such as atrial fibrillation not seen during ED workup)
- Two groups that may require inpatient or urgent outpatient workup
- Known heart disease including CHF, severe valvular disease, severe CAD, history of MI, rheumatic heart disease
- Patients with no clear cause of TIA and no classic risk factors (such as paroxysmal atrial fibrillation, severe valvular disease, PFO)
External Links
See Also
References
- ↑ 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.
- ↑ 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.
- ↑ Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006; 354(4):387–396.
- ↑ 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.
- ↑ 5.0 5.1 ACEP Clinical Policy: Suspected Transient Ischemic Attack full text Cite error: Invalid
<ref>
tag; name "ACEP" defined multiple times with different content - ↑ Nederkoorn PJ, Mali WP, Eikelboom BC, et al. Preoperative diagnosis of carotid artery stenosis. Accuracy of noninvasive testing. Stroke. 2002;33:2003-2008.
- ↑ Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, Kim AS, Lindblad AS, Palesch YY. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med. 2018 Jul 19;379(3):215-225.
- ↑ 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.
- ↑ Stead LG, Suravaram S. An assessment of the incremental value of the ABCD2 score in the emergency department evaluation of transient ischemic attack. Ann Emerg Med. 2011 Jan;57(1):46-51.
- ↑ Ghia D, Thomas P. Low positive predictive value of the ABCD2 score in emergency department transient ischaemic attack diagnoses: the South Western Sydney transient ischaemic attack study. Intern Med J. 2012 Aug;42(8):913-8.
- ↑ Boulanger JM, Lindsay MP, Gubitz G, et al. Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. Int J Stroke. 2018;:1747493018786616.
- ↑ 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.
- ↑ Johnston SC, et al. National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol. 2006; 60(3):301-13.
- ↑ Ross MA, Compton S, Medado P, et al. An emergency department diagnostic protocol for patients with transient ischemic attack: a randomized controlled trial. Ann Emerg Med. 2007;50:109-119