Transient ischemic attack

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)