Transient ischemic attack

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

Prognosis

• ABCD2 Score
  • Risk of stroke at 2d, 7d, and 90d from TIA
  • Although prognostic, evidence-based admission thresholds have not been determined
• 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	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%

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

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

Admission Criteria

AHA/ASA Guidelines

• 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

National Stroke Association

• Hospitalization for pts with first TIA w/in past 24-48hr
• Recommended admission for pts w/ the following:
  • Crescendo TIA
  • Duration of symptoms >1hr
  • Symptomatic carotid stenosis >50%
  • Known cardiac source of embolus
  • Known hypercoaguable state
  • High risk of early stroke after TIA

See Also

• CVA (Main)

Source

• Stroke 2009;40[6]:2276