Transient ischemic attack: Difference between revisions

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==Background==
==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. <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]]


DDX
==Differential Diagnosis==
{{Stroke DDX}}


Ischemic...
==Evaluation==
{{Stroke workup}}


    Thrombosis...atherosclerosis, vasculitis, dissection
==Management==
 
*Little acute management (given normally resolution of symptoms)
    Embolic...cardiac, CAS, hypercoagulable
*Consider [[Aspirin]] 325 mg PO (once hemorrhage ruled-out) for low risk TIA (ABCD2 score < 4)
 
*Consider dual [[antiplatelet]] therapy for high risk TIA (ABCD2 score ≥ 4)<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>
    Vasospasm
**Load with [[Aspirin]] 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
    Hypotension/watershed
 
 
==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)  Permisive 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==
==Disposition==
===ACEP Guidelines<ref name="ACEP"></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==


===Canadian TIA Score===
 
*The score offers better performance than ABCD2 in predicting stroke risk after TIA, particularly low risk. <ref>Perry JJ et al. Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study.BMJ 2021 Feb 4.</ref>
ABCD2 SCORE
'''Item Scoring'''
 
*Clinical Findings:
(1) Age >60 y
**1. First TIA (in lifetime) (2 pt)  
 
**2. Symptoms ≥10 minutes (2 pt)
(1) Blood pressure (SBP >140 or diastolic >90)
**3. Past history of carotid stenosis (2 pt)
 
**4. Already on antiplatelet therapy (3 pt)
(2) Clinical: unilateral weakness
**5. History of gait disturbance (1 pt)
 
**6. History of unilateral weakness (1 pt)
(1) Clinical: speech disturbance without weakness
**7. History of vertigo (-3 pts)
 
**8. Initial triage diastolic blood pressure ≥110 mm Hg (3 pt)
(1) Duration symptoms 10-60 min
**9. Dysarthria or aphasia (history or examination) (3 pt)
 
(2) Duration symptoms >60 min
 
(1) Diabetes
 
 
Admit for score >3
 
(none with less had CVA w/i one week in study)
 
Only numbness with low score is low risk: outpt f/u with Neuro
 
 
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.
 
 
if a-fib, admit, heparin.
 
 
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, ASA + Plavix 75mg po QD
 
    or,        Plavix alone. 
 
 
TIA ADMIT (nmlly neg sy; <1hr)
 
1) any Johnson criteria


2) <1 wk from onset
*Investigations in the emergency department:
**1.Atrial fibrillation on electrocardiogram (2 pt)
**2.Infarction (new or old) on computed tomography (1 pt)
**3.Platelet count≥400×109/L (2 pt)
**4.Glucose ≥15 mmol/L (3pt)


   
{| class="wikitable"
|-
| '''Points'''
| '''Stroke Risk'''
| '''Risk of Stroke or Carotid Revascularization in 7 Days'''  
|-
| -3-3
| Low
| .5%
|-
| 4-8
| Medium Risk
| 2.3%
|-
| ≥9
| High
| 5.9%
|}


==Source==
===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
*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%<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>


'''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)


DONALDSON (Smith, Lampe, NEJM '07, Pani)
{| class="wikitable"
|-
| '''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<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


==External Links==
*[http://www.mdcalc.com/abcd2-score-for-tia/ MDCalc ABCD2 Score]
*[https://www.acep.org/patient-care/clinical-policies/suspected-transient-ischemic-attack/ ACEP Clinical Policy: Suspected Transient Ischemic Attack]


==See Also==
*[[CVA (Main)]]
*[[ACEP clinical policies]]


[[Category:Neuro]]
==References==
<references/>
[[Category:Neurology]]

Latest revision as of 02:43, 18 May 2022

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 325 mg PO (once hemorrhage ruled-out) for low risk TIA (ABCD2 score < 4)
  • Consider dual antiplatelet therapy for high risk TIA (ABCD2 score ≥ 4)[7]
    • Load with Aspirin 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

Canadian TIA Score

  • The score offers better performance than ABCD2 in predicting stroke risk after TIA, particularly low risk. [9]

Item Scoring

  • Clinical Findings:
    • 1. First TIA (in lifetime) (2 pt)
    • 2. Symptoms ≥10 minutes (2 pt)
    • 3. Past history of carotid stenosis (2 pt)
    • 4. Already on antiplatelet therapy (3 pt)
    • 5. History of gait disturbance (1 pt)
    • 6. History of unilateral weakness (1 pt)
    • 7. History of vertigo (-3 pts)
    • 8. Initial triage diastolic blood pressure ≥110 mm Hg (3 pt)
    • 9. Dysarthria or aphasia (history or examination) (3 pt)
  • Investigations in the emergency department:
    • 1.Atrial fibrillation on electrocardiogram (2 pt)
    • 2.Infarction (new or old) on computed tomography (1 pt)
    • 3.Platelet count≥400×109/L (2 pt)
    • 4.Glucose ≥15 mmol/L (3pt)
Points Stroke Risk Risk of Stroke or Carotid Revascularization in 7 Days
-3-3 Low .5%
4-8 Medium Risk 2.3%
≥9 High 5.9%

ABCD2 Score[10]

  • 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%[11][12]

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[13]
    • 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
  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. ↑ Perry JJ et al. Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study.BMJ 2021 Feb 4.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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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