Transient ischemic attack: Difference between revisions
| Line 27: | Line 27: | ||
* Head CT | * Head CT | ||
* Labs | * Labs | ||
** CBC | ** CBC (thrombocytosis) | ||
** Chemistry | ** Chemistry (hyponatremia) | ||
** Coags | ** Coags | ||
* ECG (a-fib) | * ECG (a-fib) | ||
| Line 47: | Line 47: | ||
Age > 60 (1 pt) | Age > 60 (1 pt) | ||
Blood pressure (SBP >140 | Blood pressure (SBP >140 OR diastolic >90) (1 pt) | ||
Clinical | Clinical Features | ||
* unilateral weakness (2 pt) | * unilateral weakness (2 pt) | ||
* speech disturbance | * isolated speech disturbance (1 pt) | ||
Duration of symptoms | |||
* | * >60 min (2 pt) | ||
* 10-59 min (1 pt) | |||
Diabetes (1 pt) | |||
Admit for score | Admit for score ≥ 3 AND presenting within 72h of symptoms | ||
(none with less had CVA within one week in study) | (none with less had CVA within one week in study) | ||
Revision as of 20:49, 2 March 2011
Definition
"Transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without infarction.” Stroke 2009;40[6]:2276
Background
1. Ischemic
- Thrombosis
- Vasculitis
- Dissection
2. Embolic
- Cardiac
- Carotids
3. Vasospasm 4. Hypotension (watershed)
DDx
- Hypoglycemia
- Infectious endocarditis
- Complex migraines
- Peripheral cranial nerve lesions
- Seizure
Work-Up
- Head CT
- Labs
- CBC (thrombocytosis)
- Chemistry (hyponatremia)
- Coags
- ECG (a-fib)
- CXR
- ?MRI/MRA or ?Neuro labs (ESR?, lipids?)
Treatment
- Head of bed lowered
- Permissive hypertension
- NS 500cc bolus, then 150cc/hr (non-CHF/fluid overloaded)
- ASA
- Heparin if cardiac embolic source/a-fib (usually different vascular territories)
Disposition
ABCD2 SCORE
Age > 60 (1 pt) Blood pressure (SBP >140 OR diastolic >90) (1 pt) Clinical Features
- unilateral weakness (2 pt)
- isolated speech disturbance (1 pt)
Duration of symptoms
- >60 min (2 pt)
- 10-59 min (1 pt)
Diabetes (1 pt)
Admit for score ≥ 3 AND presenting within 72h of symptoms
(none with less had CVA within 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)