Transient ischemic attack: Difference between revisions
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==Definition== | |||
(AHA and ASA)"Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without infarction.” Stroke 2009;40[6]:2276 | |||
== == | |||
==Background== | ==Background== | ||
Ischemic | |||
Thrombosis, atherosclerosis, vasculitis, dissection | |||
Thrombosis | |||
Embolic...cardiac, CAS, hypercoagulable | Embolic...cardiac, CAS, hypercoagulable | ||
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Hypotension/watershed | Hypotension/watershed | ||
DDx== | |||
Hypoglycemia | |||
Infectious endocarditis | |||
Complex migraines | |||
Peripheral cranial nerve lesions | |||
Seizure | |||
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1) Head of bed lowered | 1) Head of bed lowered | ||
2) | 2) Permissive hypertension | ||
3) NS 500cc bolus, then 150cc/hr (non-CHF/fluid overloaded) | 3) NS 500cc bolus, then 150cc/hr (non-CHF/fluid overloaded) | ||
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Admit for score >3 | Admit for score >3 and presenting within 72h of symptoms | ||
(none with less had CVA w/i one week in study) | (none with less had CVA w/i one week in study) | ||
Only numbness with low score is low risk: outpt f/u with Neuro | Only numbness with low score is low risk: outpt f/u with Neuro | ||
Also admit: | |||
Crescendo TIA | |||
Duration >1h | |||
Symptomatic carotid stenosis > 50% | |||
Known cardiac source of embolus | |||
Known hypercoaguable state | |||
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Johnston, SC et al. JAMA. Dec 13, 2000. | Johnston, SC et al. JAMA. Dec 13, 2000. | ||
To determine which pts need to be admitted vs rapid outpatient evaluation. | |||
10% of pts with TIA developed CVA within 90 days. | 10% of pts with TIA developed CVA within 90 days. | ||
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(also, at increased risk of CVA if >4 TIA spells within last 2 wks, or escalating / crescendo TIA) | (also, at increased risk of CVA if >4 TIA spells within last 2 wks, or escalating / crescendo TIA) | ||
Transient monocular blindness (amaurosis fugax) more benign. | |||
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----if ASA intolerant or ASA failure, then Ticlopidine. consider Coumadin. | ----if ASA intolerant or ASA failure, then Ticlopidine. consider Coumadin. | ||
or, Plavix alone. | or, Plavix alone. | ||
Revision as of 23:43, 1 March 2011
Definition
(AHA and ASA)"Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without infarction.” Stroke 2009;40[6]:2276
Background
Ischemic
Thrombosis, atherosclerosis, vasculitis, dissection
Embolic...cardiac, CAS, hypercoagulable
Vasospasm
Hypotension/watershed
DDx==
Hypoglycemia
Infectious endocarditis
Complex migraines
Peripheral cranial nerve lesions
Seizure
Work-Up
1) Head CT
2) CBC, Chem 10, Coags,
3) ECG (a-fib.)
4) CXR
5) ?MRI/MRA or ?Neuro (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
(1) Age >60 y
(1) Blood pressure (SBP >140 or diastolic >90)
(2) Clinical: unilateral weakness
(1) Clinical: speech disturbance without weakness
(1) Duration symptoms 10-60 min
(2) Duration symptoms >60 min
(1) Diabetes
Admit for score >3 and presenting within 72h of symptoms
(none with less had CVA w/i one week in study)
Only numbness with low score is low risk: outpt f/u with Neuro
Also admit:
Crescendo TIA
Duration >1h
Symptomatic carotid stenosis > 50%
Known cardiac source of embolus
Known hypercoaguable state
Literature:
Johnston, SC et al. JAMA. Dec 13, 2000.
To determine which pts need to be admitted vs rapid outpatient evaluation.
10% of pts with TIA developed CVA within 90 days.
50% (5%) within 2 days.
Kaiser Study
Greater risk of CVA (admit any)
1. Age >60
2. DM
3. Duration >10min
4. Motor weakness
5. Speech impairment (dysarthria/ aphasia)
Numbness is low risk: outpt f/u with Neuro
(also, at increased risk of CVA if >4 TIA spells within last 2 wks, or escalating / crescendo TIA)
Transient monocular blindness (amaurosis fugax) more benign.
in Mayo Clinic Proceedings, Nov 1994. 33% of pts with TIA will have CVA within 5 yrs.
high risk... inpt w/u
low risk... expedited outpt w/u
ECG for a-fib
Echocardiogram, TEE most sensitive. prosthetic valves... DCM... mural thrombosis, SBE, post-MI.
Carotid duplex, if +, cerebral angiogram, then CEA.
----ASA
----Heparin if cardiac embolic source/a-fib. usually different vascular territories.
----if ASA intolerant or ASA failure, then Ticlopidine. consider Coumadin.
or, Plavix alone.
TIA ADMIT (nmlly neg sy; <1hr)
1) any Johnson criteria
2) <1 wk from onset
Source
DONALDSON (Smith, Lampe, NEJM '07, Pani)