Transient Ischemic attack

Definition
as episodes of transient cerebral ischemia with acute neurologic changes resolving within 24 hours of onset (National Institute of Neurologic Diseases and Stroke ad hoc Committee on Cerebrovascular Diseases, 1975)

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Frequency

In the United States, TIA annual incidence rates range from 37 to 107 per 100,000 people per year. 200,000 and 500,000 people have TIA each year in the United States (Johnston, 2002) 5 million adults in the United States have had a TIA, and many are undiagnosed (Johnston et al., 2003)

Dyken and colleagues (1977) 1,323 patients with TIA-like symptoms 66 % of patients who had carotid artery symptoms 34 % vertebral artery symptoms 63% of those male Median age 63 years

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Whats the duration of TIA

Levy (1988) 1,343 hospitalized patients with TIA and RIND 56 % were male mean age of 66 years 382 patients, TIA was diagnosed 191 (50%) had episodes that lasted less than 30 minutes 9% had symptoms that lasted 3060 minutes These authors suggested less than 24 hours as the longest permissible duration for TIA

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Werdelin and Juhler (1988) 78 patients TIA admitted to hospital whether the differential diagnosis of stroke versus TIA could be made earlier than 24 hours Within 1 hour, 50% of TIA patients had recovered within 4 hours, 90% recovered CT scans obtained on half of the patients with TIA - infarction in two - multiple infarctions in one - no infarction in the remainder of the cases

TIA Symptoms According to Cerebral Circulation

The decisions made in the case of a possible acute TIA :

admitted evaluated expeditiously as outpatients evaluated in a less than expeditious manner

Goldstein and colleagues Retrospective, Outpatients-first-ever TIA and minor stroke 27 primary care medical practices eastern United States 95 with TIA and 81 with stroke 79 % of TIA vs 88% with stroke were evaluated on the day when their symptoms occurred 2% of the TIA vs 10% of the stroke were admitted

Why should be paid attention?

Short-term prognosis for TIA

Led by Matthew Giles, MRCP, and Peter Rothwell, MD, PhD, FRCP (University of Oxford, United Kingdom) large systematic review, the risk for major stroke after TIA is: - 5.2% at 7 days - 3.2% at 2 days.

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Short-term prognosis for TIA

In a Kaiser Permanente cohort Emergency dept 1707 patients TIA (mean age, 72 years) - 180 patients (10.5%) returned with a stroke 91 (5%) within 2 days - 428 patients (25.1%) with stroke or other adverse events occurred in the 90 days : = 44 hospitalizations for cardiovascular events (2.6%) = 45 deaths (2.6%) = 216 recurrent TIAs (12.7%).

Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000;284:2901-2906. http://www.medscape.com/pages/editorial/casecme/2005/4709/levine/levine-02-2

Five factors were independently associated with stroke

age greater than 60 years (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-2.7; P = .01) diabetes mellitus (OR, 2.0; 95% CI, 1.42.9; P < .001) symptom duration longer than 10 minutes (OR, 2.3; 95% CI, 1.3-4.2; P = .005) weakness (OR, 1.9; 95% CI, 1.4-2.6; P < .001) speech impairment (OR, 1.5; 95% CI, 1.1-2.1; P = .01).

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7-Day Stroke Risk After TIA by Treatment Type

Setting Nonurgent Treatment Urgent Treatment

Patients With Subsequent Stroke (%) 11 0.9

95% CI 8.6 13.5 0.0 1.9

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Pathophysiology
Transient ischemia to the brain The etiology of TIA : Atrial fibrillation Carotid artery disease Large artery disease Small artery disease (Johnston, 2002), or other causes Some less common causes include hypercoagulable states, illicit drug use (Feinberg et al., 1994), and fibromuscular dysplasia (Slovut & Olin, 2004).
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Whats the Differential Diagnosis?

Cerebrovascular (TIA or stroke) Migraine Seizure Mass lesion (tumor or subdural hematoma) Hypoglycemia (toxic-metabolic) Infectious (encephalitis) Functional.

What should be the next steps?

magnetic resonance imaging (MRI) carotid duplex Doppler ultrasonography electrocardiography (ECG) Echocardiography selected laboratory studies for stroke risk factors: glucose, CBC and platelet count, lipid panel

Goldstein and colleagues Retrospective, Outpatients-first-ever TIA and minor stroke 27 primary care medical practices eastern United States 95 with TIA and 81 with stroke 79 % of TIA vs 88% with stroke were evaluated on the day when their symptoms occurred 2% of the TIA vs 10% of the stroke were admitted A CTscan or MRI scan in 23% TIA, 37% stroke Carotid ultrasound in 40% TIA, 14% stroke ECGs in 18% TIA, 21% stroke Echocardiograms in 19% TIA, 14% stroke

1. Goldstein LB, Bian J, Samsa GP, Bonito AJ, Lux LJ, Matchar DB. New transient ischemic attack and stroke:
outpatient management by primary care physicians. Arch Intern Med. 2000;160:2941-2946.

Recommended laboratory studies

complete blood count with platelet count chemistry profile (with fasting cholesterol level and glucose tolerance) prothrombin time and activated partial thromboplastin time erythrocyte sedimentation rate (ESR) with syphilis serology lipid profile.

Whats the risk for stroke after TIA?

5% within the first 2 days in the Kaiser Permanente cohort1 12% in the first week in the study by Rothwell and colleagues2

1. Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000;284:2901-2906. 2. Rothwell PM et al. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet. 2005;366:29-36.

High risk for short-term new stroke

"ABCD" risk stratification3 to identify TIA patients at high risk for short-term new stroke is score as 5 A score for 7-day risk for stroke was derived from a 6-point score : Age >/= 60 = 1 point; Blood pressure systolic > 140 mm Hg and/or diastolic >/= 90 mm Hg = 1 point; Clinical features (unilateral weakness = 2 points, speech disturbance without weakness = 1 point, and other symptoms = 0 points); and Duration of symptoms in minutes >/= 60 = 2 points, 1059 = 1 point, < 10 = 0 points.

Rothwell PM et al. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet. 2005;366:29-36.

Nonischemic Causes of TIA Symptoms

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