Transient ischemic attack: Difference between revisions

(Text replacement - " pts" to " patients")
(Text replacement - " ==" to "==")
Line 1: Line 1:
== Background ==
== Background==
*Abbreviation: TIA
*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. <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>  
*'''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>  
Line 14: Line 14:
{{Stroke DDX}}
{{Stroke DDX}}


== Diagnosis ==
== Diagnosis ==
{{Stroke workup}}
{{Stroke workup}}


Line 61: Line 61:
None with score <3 had CVA within one week in study
None with score <3 had CVA within one week in study


== Disposition ==
== Disposition ==
=== 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> ===
=== 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 w/ TIA who present w/in 72 hr of symptom onset and have:
*Reasonable to hospitalize patients w/ TIA who present w/in 72 hr of symptom onset and have:
**ABCD2 score of ≥ 3  
**ABCD2 score of ≥ 3  
Line 68: Line 68:
**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<ref>Johnston SC, et al. National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol. 2006; 60(3):301-13.</ref> ===
=== 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 patients with first TIA w/in past 24-48hr
*Hospitalization for patients with first TIA w/in past 24-48hr
*Recommended admission for patients w/ the following:
*Recommended admission for patients w/ the following:
Line 78: Line 78:
**High risk of early stroke after TIA
**High risk of early stroke after TIA


== External Links ==
== External Links==
[http://www.mdcalc.com/abcd2-score-for-tia/ MDCalc ABCD2 Score]
[http://www.mdcalc.com/abcd2-score-for-tia/ MDCalc ABCD2 Score]


== See Also ==
== See Also==
*[[CVA (Main)]]  
*[[CVA (Main)]]  


Revision as of 05:21, 7 July 2016

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

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)

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 patients)
    • Duration of symptoms
      • 10-59 min (1 pt)
      • >60 min (2 patients)
    • 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 patients 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 patients with first TIA w/in past 24-48hr
  • Recommended admission for patients 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. ↑ 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.
  8. ↑ 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.
  9. ↑ Johnston SC, et al. National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol. 2006; 60(3):301-13.
Retrieved from "https://www.wikem.org/w/index.php?title=Transient_ischemic_attack&oldid=81944"