Transient Ischemic Attack: Reviewing the Evolution of the Definition, Diagnosis, Risk Stratification, and Management for the Emergency Physician
Section snippets
Clinical presentation
When approaching patients with symptoms suggestive of a TIA, the physician's first objective is to determine whether the described episode is consistent with TIA or not. Misdiagnosis rates among emergency physicians has been reported to be as high as 60%,23 and discordance among neurologists in the diagnosis of TIA by history is thought to be between 42% and 86%.24, 25 Moreover, one recent study found that agreement in the diagnosis of TIA was low even among stroke-trained neurologists,
History
The diagnosis of TIA is clinical, although the new definition implies that brain imaging is negative for infarction. Although it can be challenging for patients to accurately describe neurologic dysfunction, the history should focus on establishing whether or not patients have the abrupt onset of focal neurologic deficits. A nationwide survey found that only 8% of laypersons were able to correctly define or identify one common symptom of TIA, so asking patients about specific associated
Risk prediction
There have been numerous attempts over the past 20 years to create a validated risk-stratification tool that is easy to apply and provides clinicians with a realistic estimate of stroke risk after TIA. The first seems to be the Stroke Prognosis Instrument published by Kernan and colleagues73 in 1991. This tool was followed by Hankey and colleagues74 in 1992, then the California Score in 2000,16 and the ABCD score in 2005.75 The ABCD2 score published in 2007 represents the combined efforts of
General Considerations
The primary goals in patients with TIA and TSI are to optimize cerebral perfusion to the ischemic tissue and to prevent a subsequent more disabling stroke. Positioning the patient with the head of the bed flat has been shown (by TCD) to increase cerebral perfusion by 20% compared with a 30° incline.100 This simple step should be done routinely unless contraindicated. As in ischemic stroke, it is generally a good idea to maintain euvolemia, and all patients with TIA should have intravenous
Disposition
Determining which patients to admit to the hospital versus observe in an observation unit or discharge with rapid follow-up is a source of uncertainty and frustration for many emergency physicians. Factors likely to contribute to varying admission thresholds include the ease of access to follow-up testing and neurology consultation, inpatient bed availability, patient expectations, and medicolegal concerns.
Some have advocated for admission policies based on the ABCD2 score. In reviewing the
Future directions
If recent history is any indication of future direction, then there will certainly be continued effort in improving stroke-risk prediction after TIA. It is clear that individual stroke risk is best estimated when the TIA cause is known and cerebrovascular disease burden has been assessed with advanced imaging studies. How to best improve risk estimation when imaging resources are limited in the short-term remains to be determined.
Serum biomarkers of cerebral ischemic injury would prove useful
Summary
The evaluation of TIA in the ED is a golden opportunity to prevent a disabling stroke. The greatest risk is in the first 48 hours after the TIA. Clinical risk stratification tools provide a partial estimation of short-term risk and may help differentiate TIAs from nonischemic events. The diagnosis is made based on history, a normal neurologic examination, and neuroimaging with absence of infarction. The 24-hour time window is no longer relevant, and most TIAs last less than 1 hour. Etiologic
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The role of optic nerve sheath diameter measurement on CT in differentiating transient ischemic attack and acute ischemic stroke
2022, Clinical Neurology and NeurosurgeryNovel Treatments for Transient Ischemic Attack and Acute Ischemic Stroke
2021, Emergency Medicine Clinics of North AmericaCitation Excerpt :A careful history focusing on the differentiation of symptoms that suggest irritative phenomenon like seizure or complex migraine can be helpful. A noncontrast CT scan is of low yield in patients with TIA and diffusion-weighted MRI is strongly preferred, but oftentimes logistically not feasible in the emergency department setting given the majority of US emergency departments do not have 24/7 access to MRI.75 Perfusion imaging modalities (both CT scans and MRI) have been shown to identify patients with focal perfusion abnormalities in 30% to 42% of patients after a TIA, some of whom had no abnormalities detected on diffusion-weighted MRI.76–78
Management of Acute Retinal Ischemia: Follow the Guidelines!
2018, OphthalmologyCitation Excerpt :Hence, a large number of studies have focused on identifying TIA patients with the highest risk of subsequent stroke. Clinical scores such as the ABCD2 score routinely used in emergency settings are helpful when triaging patients with transient neurologic symptoms.28,38 This score gives points to parameters such as Age 60 or greater, Blood pressure 140/90 mmHg or more, Clinical features of focal weakness or speech impairment, Duration of the neurologic symptom greater than 1 hour, and Diabetes.
Distinct inflammatory responses differentiate cerebral infarct from transient ischaemic attack
2017, Journal of Clinical NeuroscienceCitation Excerpt :The results of this study provide evidence of increasing immune response severity between cerebral infarct and TIA and add further weight to the body of evidence suggesting the use of MMP-9 and S100A12 as potential biomarkers or therapeutic targets. This may have important implications given the difficulties in differentiating ischemic stroke and TIA early following onset, and the absence of reliable biomarkers for the diagnosis of ischaemic stroke [15–18]. A larger study is needed however to clarify the mechanisms and significance behind the decreased expression of GzmB in the setting of acute stroke, along with the role of neutrophils in the secondary inflammatory process.
Neurologic Emergencies in the Elderly
2016, Emergency Medicine Clinics of North AmericaCitation Excerpt :All patients should undergo an evaluation and workup by a persons with clinical stroke expertise (Box 4). Neuroimaging, preferably by MRI, should be within 24 hours of symptom onset and include imaging of the cervicocephalic vessels.31,36–38 Patients suffering a TIA should be evaluated via inpatient hospitalization, an observation unit, or a dedicated outpatient 24-hour TIA clinic to ensure that all necessary tests and monitoring is completed.36,38