Transient ischemic attack

Background

• Definition: Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia without infarction
• Should be viewed as analogous to unstable angina
  • 90-day stroke risk after TIA is 9.5%

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 Migraine
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

ABCD2 SCORE

• Risk of stroke at 2d, 30d, and 90d from TIA
• 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	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

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

National Stroke Association

Hospitalization 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

See Also

CVA (Main)

Source

• Stroke 2009;40[6]:2276