Transient ischemic attack: Difference between revisions

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==Background==
== 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
*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%
**90-day stroke risk after TIA is 9.5%


== Background ==
== Background ==
#Ischemic
 
##Thrombosis
#Ischemic  
##Vasculitis
##Thrombosis  
##Dissection
##Vasculitis  
#Embolic
##Dissection  
##Cardiac
#Embolic  
##Carotids
##Cardiac  
#Vasospasm
##Carotids  
#Vasospasm  
#Hypotension (watershed)
#Hypotension (watershed)


== DDx ==
== DDx ==
#[[Hypoglycemia]]
 
#Infectious endocarditis
#[[Hypoglycemia]]  
#Complex [[Migraine]]
#Infectious endocarditis  
#Peripheral cranial nerve lesions
#Complex [[Migraine]]  
#Peripheral cranial nerve lesions  
#[[Seizure]]
#[[Seizure]]


== Work-Up ==
== Work-Up ==
#[[Head CT]]
 
#Labs
#[[Head CT]]  
##CBC (thrombocytosis)
#Labs  
##Chemistry (hyponatremia)
##CBC (thrombocytosis)  
##Coags
##Chemistry (hyponatremia)  
#ECG (a-fib)
##Coags  
#CXR
#ECG (a-fib)  
#CXR  
# ?MRI/MRA or ?Neuro labs (ESR?, lipids?)
# ?MRI/MRA or ?Neuro labs (ESR?, lipids?)


== Treatment ==
== Treatment ==
#Head of bed lowered
 
#Permissive hypertension
#Head of bed lowered  
#NS 500cc bolus, then 150cc/hr (non-CHF/fluid overloaded)
#Permissive hypertension  
#ASA
#NS 500cc bolus, then 150cc/hr (non-CHF/fluid overloaded)  
#ASA  
#Heparin if cardiac embolic source/a-fib (usually different vascular territories)
#Heparin if cardiac embolic source/a-fib (usually different vascular territories)


== Disposition ==
== Disposition ==
===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:


#ABCD2 score of ≥ 3
=== ABCD2 SCORE ===
#ABCD2 score of 0-2 and uncertainty that the diagnostic workup can be completed within two days as an outpatient
*Age >60yr (1 pt)  
#ABCD2 score of 0-2 and other evidence that the event was caused by focal ischemia
*BP (SBP >140 OR diastolic >90) (1 pt)  
 
*Clinical Features  
=== ABCD2 SCORE ===
**Isolated speech disturbance (1 pt)  
*Age > 60 (1 pt)
**Unilateral weakness (2 pts)  
*Blood pressure (SBP >140 OR diastolic >90) (1 pt)
*Duration of symptoms  
*Clinical Features
**10-59 min (1 pt)  
**unilateral weakness (2 pt)
**>60 min (2 pts)  
**isolated speech disturbance (1 pt)
*DM (1 pt)
*Duration of symptoms
**>60 min (2 pt)
**10-59 min (1 pt)
*Diabetes (1 pt)


{| style="width: 500px" border="1" cellpadding="1" cellspacing="1"
{| style="width: 500px" border="1" cellpadding="1" cellspacing="1"
|-
|-
| '''Points<br/>'''
| '''Points<br>'''  
| '''Risk<br/>'''
| '''Risk<br>'''  
| '''Two Days<br/>'''
| '''Two Days<br>'''  
| '''Seven Days <br/>'''
| '''Seven Days <br>'''  
| '''90 Days<br/>'''
| '''90 Days<br>'''
|-
|-
| 0-3<br/>
| 0-3<br>  
| Low<br/>
| Low<br>  
| 1.0%<br/>
| 1.0%<br>  
| 1.2%<br/>
| 1.2%<br>  
| 3.1%<br/>
| 3.1%<br>
|-
|-
| 4-5<br/>
| 4-5<br>  
| Moderate<br/>
| Moderate<br>  
| 4.1%<br/>
| 4.1%<br>  
| 5.9%<br/>
| 5.9%<br>  
| 9.8%<br/>
| 9.8%<br>
|-
|-
| 6-7<br/>
| 6-7<br>  
| High<br/>
| High<br>  
| 8.1%<br/>
| 8.1%<br>  
| 11.7%<br/>
| 11.7%<br>  
| 17.8%<br/>
| 17.8%<br>
|}
|}


None with score < 3 had CVA within one week in study
None with score &lt; 3 had CVA within one week in study  


===National Stroke Association===
=== AHA/ASA Guidelines ===
Hospitalization for pts with first TIA w/in past 24-48 hours, and is generally recommended for pts with the following conditions:


#Crescendo TIA
Reasonable to hospitalize patients with TIA who present w/in 72 hr of symptom onset and meet any of the following criteria:
#Duration of symptoms > 1hr
 
#Symptomatic carotid stenosis > 50%
#ABCD2 score of ≥ 3
#Known cardiac source of embolus
#ABCD2 score of 0-2 and uncertainty that the diagnostic workup can be completed within two days as an outpatient
#Known hypercoaguable state
#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:
 
#Crescendo TIA  
#Duration of symptoms &gt; 1hr  
#Symptomatic carotid stenosis &gt; 50%  
#Known cardiac source of embolus  
#Known hypercoaguable state  
#High risk of early stroke after TIA
#High risk of early stroke after TIA


TIA ADMIT (nmlly neg sy; <1hr)
TIA ADMIT (nmlly neg sy; &lt;1hr)  
#any Johnson criteria
 
#<1 wk from onset
#any Johnson criteria  
#&lt;1 wk from onset
 
== See Also ==
 
[[CVA (Main)]]


==See Also==
== Source  ==
[[CVA (Main)]]


== Source ==
*Stroke 2009;40[6]:2276
*Stroke 2009;40[6]:2276


[[Category:Neuro]]
[[Category:Neuro]]

Revision as of 04:14, 29 September 2011

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

  • 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
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