Transient ischemic attack: Difference between revisions

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== Background ==
==Background==
*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>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>  
*Abbreviation: TIA
*Should be viewed as analogous to unstable angina  
*'''New Definition:''' a brief episode of neurologic dysfunction caused by focal brain, spinal cord 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>  
**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<ref name="Albers"></ref>
*Since 15% of strokes are preceded by TIA, timely eval of high risk conditions like [[Atrial Fibrillation]] and [[Carotid stenosis|Carotid Stenosis]] is important


==Clinical Features==
*Focal [[weakness]] (Paralysis or paresis of the face, arm, or leg and typically unilateral)
*[[Dysarthria]] or dysphasia or aphasia
*[[visual disturbances|Vision changes]] (Field deficits, [[vision loss|blindness]], or [[diplopia]])
*Changes in balance or [[ataxia|coordination]]
==Differential Diagnosis==
{{Stroke DDX}}
==Evaluation==
{{Stroke workup}}
==Management==
*Little acute management (given normally resolution of symptoms)
*Consider [[aspirin]] (once hemorrhage ruled-out)
*Consider dual [[antiplatelet]] therapy for high risk TIAs<ref>Johnston SC, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, Kim AS, Lindblad AS, Palesch YY. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med. 2018 Jul 19;379(3):215-225.</ref>
**Load with [[ASA]] 325 mg chewed, followed by ASA 81 mg PO daily
**Load with [[clopidogrel]] 300 mg PO followed by 75 mg daily for 3 weeks only
==Disposition==
===ACEP Guidelines<ref name="ACEP">ACEP Clinical Policy: Suspected Transient Ischemic Attack[https://www.acep.org/Physician-Resources/Policies/Clinical-policies/Clinical-Policy-Suspected-Transient-Ischemic-Attack/ full text]</ref>===
*Level B: In adult patients with suspected TIA, do not rely on current existing risk stratification instruments (eg, age, blood pressure, clinical features, duration of TIA and presence of diabetes [ABCD2] score) to identify TIA patients who can be safely discharged from the ED.
**In contrast to the 2009 AHA/ASA recommendations that were based on limited research, the ABCD2 does not sufficiently identify the short-term risk for stroke to use alone as a risk-stratification instrument.
**Multiple other risk-stratification instruments have been evaluated less frequently than the ABCD2 score. None have demonstrated the ability to identify individual patients at sufficiently low short-term risk for stroke to use alone as a risk-stratification instrument.
*Level B: A rapid ED based diagnostic protocol can be used to safely identify patients at short-term risk for stroke.
**Study based on observation units and outpatient TIA clinics<ref>Ross MA, Compton S, Medado P, et al. An emergency department diagnostic protocol for patients with transient ischemic attack: a randomized controlled trial. Ann Emerg Med. 2007;50:109-119</ref>
[[File:TIA ADP.png|thumbnail|Example of a rapid ED protocol for TIA]]
==Prognosis==
===ABCD2 Score<ref>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.</ref>===
===ABCD2 Score<ref>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.</ref>===
*Risk of stroke at 2d, 7d, and 90d from TIA
*Risk of stroke at 2d, 7d, and 90d from TIA
*Although prognostic, evidence-based admission thresholds have not been determined
*Although prognostic, evidence-based admission thresholds have not been determined
*Score
*None with score <3 had CVA within one week in study
**Age >60yr (1 pt)  
*Studies have failed to validate the ABCD2 score, and may cause physicians to incorrectly classify ~8% of patients as low risk, with sensitivity of the score for high risk patients only ~30%<ref>Stead LG, Suravaram S. An assessment of the incremental value of the ABCD2 score in the emergency department evaluation of transient ischemic attack. Ann Emerg Med. 2011 Jan;57(1):46-51.</ref><ref>Ghia D, Thomas P. Low positive predictive value of the ABCD2 score in emergency department transient ischaemic attack diagnoses: the South Western Sydney transient ischaemic attack study. Intern Med J. 2012 Aug;42(8):913-8.</ref>
**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)


'''Scoring'''
*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)
*[[Diabetes mellitus]] (1 pt)


{| class="wikitable"
{| class="wikitable"
|-
|-
| '''Points<br>'''  
| '''Points'''  
| '''Stroke Risk<br>'''  
| '''Stroke Risk'''  
| '''Two Days<br>'''  
| '''Two Days'''  
| '''Seven Days <br>'''  
| '''Seven Days'''  
| '''90 Days<br>'''
| '''90 Days'''
|-
|-
| 0-3<br>
| 0-3
| Low<br>
| Low
| 1.0%<br>
| 1.0%
| 1.2%<br>
| 1.2%
| 3.1%<br>
| 3.1%
|-
|-
| 4-5<br>
| 4-5
| Moderate<br>
| Moderate
| 4.1%<br>
| 4.1%
| 5.9%<br>
| 5.9%
| 9.8%<br>
| 9.8%
|-
|-
| 6-7<br>
| 6-7
| High<br>
| High
| 8.1%<br>
| 8.1%
| 11.7%<br>
| 11.7%
| 17.8%<br>
| 17.8%
|}
|}


None with score <3 had CVA within one week in study
*According to the 2018 Canadian Heart and Stroke Guideline, the '''Clinical''' component of the ABCD2 score is the most important prognostic feature<ref>Boulanger JM, Lindsay MP, Gubitz G, et al. Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. Int J Stroke. 2018;:1747493018786616.</ref>
**Very high risk for recurrent stroke are the following symptoms that have occurred within the last 48 hours
***Transient, fluctuating or persistent unilateral weakness (face, arm and/or leg)
***Transient, fluctuating or persistent language/speech disturbance
***And/or fluctuating or persistent symptoms without motor weakness or language/speech disturbance


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


== DDx  ==
==See Also==
*See [[CVA]]
 
== Work-Up  ==
#[[Head CT]]
#Labs
##CBC
##Chemistry
##Coags
#ECG (a-fib)
#CXR
#?MRI/MRA or ?neuro labs (ESR, lipids)
 
== 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> ===
*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<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 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 ==
[http://www.mdcalc.com/abcd2-score-for-tia/ MDCalc ABCD2 Score]
 
== See Also ==
*[[CVA (Main)]]  
*[[CVA (Main)]]  


== Source  ==
==References==
*Stroke 2009;40[6]:2276
*Tintinalli
 
===Works Sited===
<references/>
<references/>
[[Category:Neuro]]
[[Category:Neurology]]

Revision as of 16:42, 3 October 2019

Background

  • Abbreviation: TIA
  • New Definition: a brief episode of neurologic dysfunction caused by focal brain, spinal cord 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]
  • Since 15% of strokes are preceded by TIA, timely eval of high risk conditions like Atrial Fibrillation and Carotid Stenosis is important

Clinical Features

Differential Diagnosis

Stroke-like Symptoms

Evaluation

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)

Management

  • Little acute management (given normally resolution of symptoms)
  • Consider aspirin (once hemorrhage ruled-out)
  • Consider dual antiplatelet therapy for high risk TIAs[7]
    • Load with ASA 325 mg chewed, followed by ASA 81 mg PO daily
    • Load with clopidogrel 300 mg PO followed by 75 mg daily for 3 weeks only

Disposition

ACEP Guidelines[5]

  • Level B: In adult patients with suspected TIA, do not rely on current existing risk stratification instruments (eg, age, blood pressure, clinical features, duration of TIA and presence of diabetes [ABCD2] score) to identify TIA patients who can be safely discharged from the ED.
    • In contrast to the 2009 AHA/ASA recommendations that were based on limited research, the ABCD2 does not sufficiently identify the short-term risk for stroke to use alone as a risk-stratification instrument.
    • Multiple other risk-stratification instruments have been evaluated less frequently than the ABCD2 score. None have demonstrated the ability to identify individual patients at sufficiently low short-term risk for stroke to use alone as a risk-stratification instrument.
  • Level B: A rapid ED based diagnostic protocol can be used to safely identify patients at short-term risk for stroke.
    • Study based on observation units and outpatient TIA clinics[8]
Example of a rapid ED protocol for TIA

Prognosis

ABCD2 Score[9]

  • Risk of stroke at 2d, 7d, and 90d from TIA
  • Although prognostic, evidence-based admission thresholds have not been determined
  • None with score <3 had CVA within one week in study
  • Studies have failed to validate the ABCD2 score, and may cause physicians to incorrectly classify ~8% of patients as low risk, with sensitivity of the score for high risk patients only ~30%[10][11]

Scoring

  • 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)
  • Diabetes mellitus (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%
  • According to the 2018 Canadian Heart and Stroke Guideline, the Clinical component of the ABCD2 score is the most important prognostic feature[12]
    • Very high risk for recurrent stroke are the following symptoms that have occurred within the last 48 hours
      • Transient, fluctuating or persistent unilateral weakness (face, arm and/or leg)
      • Transient, fluctuating or persistent language/speech disturbance
      • And/or fluctuating or persistent symptoms without motor weakness or language/speech disturbance

External Links

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. ↑ 5.0 5.1 ACEP Clinical Policy: Suspected Transient Ischemic Attack full text Cite error: Invalid <ref> tag; name "ACEP" defined multiple times with different content
  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, Easton JD, Farrant M, Barsan W, Conwit RA, Elm JJ, Kim AS, Lindblad AS, Palesch YY. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med. 2018 Jul 19;379(3):215-225.
  8. ↑ Ross MA, Compton S, Medado P, et al. An emergency department diagnostic protocol for patients with transient ischemic attack: a randomized controlled trial. Ann Emerg Med. 2007;50:109-119
  9. ↑ 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.
  10. ↑ Stead LG, Suravaram S. An assessment of the incremental value of the ABCD2 score in the emergency department evaluation of transient ischemic attack. Ann Emerg Med. 2011 Jan;57(1):46-51.
  11. ↑ Ghia D, Thomas P. Low positive predictive value of the ABCD2 score in emergency department transient ischaemic attack diagnoses: the South Western Sydney transient ischaemic attack study. Intern Med J. 2012 Aug;42(8):913-8.
  12. ↑ Boulanger JM, Lindsay MP, Gubitz G, et al. Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. Int J Stroke. 2018;:1747493018786616.
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