Transient ischemic attack: Difference between revisions
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*'''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> | ||
== | ==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== | ==Differential Diagnosis== |
Revision as of 14:01, 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]
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
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)
- 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)
ABCD2 Score[7]
- 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)
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% |
None with score <3 had CVA within one week in study
Disposition
AHA/ASA Guidelines[8]
- 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[9]
- 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
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.
- ↑ ACEP Clinical Policy: Suspected Transient Ischemic Attack full text
- ↑ 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, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack.Lancet. 2007; 369(9558):283-92.
- ↑ 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.