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Transient ischemic attack

Last updated: September 28, 2020

Summary

Transient ischemic attack (TIA) is a temporary, focal cerebral ischemic event that results in reversible neurological symptoms but is not associated with a visible acute infarct on neuroimaging. Cardiogenic embolism (e.g., from atrial fibrillation) and atherosclerosis (e.g., carotid artery stenosis) are the most commonly identified etiologies. Symptoms depend on the affected territory and may mimic an acute stroke; however, symptoms are transient. Because patients with TIA have an increased stroke risk, early diagnosis and initiation of secondary preventive therapies for subsequent stroke are vital. Management typically includes urgent neuroimaging, antithrombotic therapy (e.g., antiplatelet therapy), and prompt determination of the underlying cause (e.g., using echocardiography and neurovascular studies) to guide targeted preventative measures, such as the management of underlying atrial fibrillation or carotid artery stenosis. See also ischemic stroke and overview of stroke.

Definition

TIA refers to temporary, focal cerebral ischemia that results in reversible neurologic deficits without acute infarction (i.e., imaging findings show no signs of infarction). [1]

Epidemiology

Etiology

Differential diagnoses

See differential diagnoses of stroke.

The differential diagnoses listed here are not exhaustive.

Clinical features

  • Acute, transient focal neurologic symptoms
  • Typically, symptoms last < 1 hour (the majority of cases resolve in < 15 minutes).
  • Symptoms depend on the affected territory (see stroke symptoms by affected vessels and stroke symptoms by affected region) and etiology. [6]
    • Embolic: often a single, discrete episode lasting hours rather than minutes
    • Lacunar/small vessel disease: Symptoms usually resemble those seen in lacunar stroke.
    • Large vessel disease/low-flow state: often recurrent episodes lasting minutes
  • Atypical symptoms may be seen. [7]

Management

Approach

  • Perform an initial clinical evaluation , immediate ECG, and point-of-care glucose.
  • Complete laboratory studies and neuroimaging (within 24 hours of symptom onset). [8][9]
  • Stratify the risk of subsequent stroke (see “Risk stratification” section).
  • Identify and treat the underlying etiology.
  • Initiate stroke prevention measures (e.g., antiplatelet agents).
  • Neurology consultation is recommended for:
    • Patients with complex or high-risk TIAs requiring admission
    • All patients in follow-up to help tailor long-term stroke prevention

If there is evidence of an acute infarct on imaging, start immediate management for an acute ischemic stroke.

Diagnostics

General principles

  • TIA is a clinical diagnosis (see “Clinical features” section).
  • The diagnostic evaluation for suspected TIA is similar to that for acute ischemic stroke (see “Diagnosis of ischemic stroke”).
  • Ruling out alternate diagnoses and early determination of etiology are key parts of the evaluation.
  • Start the workup as soon as possible following symptom onset and within 24 hours of patient presentation. [8][10]

Laboratory studies [8][10]

  • Immediate: serum glucose
  • Subsequent (within 24 hours of presentation)
  • Optional
    • Hypercoagulable workup: Consider after initial diagnostic findings, notably in younger patients with TIA and no vascular risk factors or identifiable cause. [1][8]
    • Toxicological screen (e.g., urine drug screen, blood alcohol level): Consider if there is clinical suspicion for drug intoxication (e.g., physical signs, history of substance misuse). [11][12]

Neuroimaging [8][10]

Neuroimaging is indicated for all patients with suspected TIA within 24 hours of presentation to rule out acute infarct.

Head CT (without IV contrast)

MRI brain

  • Indication: DW-MRI is the recommended imaging modality for a suspected TIA. [8]
  • Supportive findings

A brain MRI is preferred for TIA evaluation, but a head CT (without IV contrast) must be performed first and immediately if there is concern for hemorrhage or acute infarction requiring reperfusion therapy.

Neurovascular studies in TIA [8][10]

  • Indication: all patients with a suspected TIA to determine the etiology and guide secondary prevention measures
  • Timing: ideally within 24 hours
  • Imaging: Modality is chosen based on patient factors and institutional preferences. [8]
  • Supportive findings

Cardiac evaluation [8][10]

Risk stratification

General considerations

  • Estimating the patient's risk of a future stroke after a TIA helps guide management decisions (e.g., further diagnostic workup, treatment, and disposition).
  • Individual risk depends on a combination of clinical and diagnostic parameters.
  • Risk score reliability remains limited and a complete clinical risk assessment is recommended.

Clinical scoring systems

The ABCD2 risk assessment score is most frequently used to assess short-term stroke risk. [15][16][17][18]

ABCD2 score [19]
Criteria Points
Age

≥ 60 years

1

Blood pressure

SBP ≥ 140 mm Hg OR DBP ≥ 90 mm Hg

1

Clinical features

Speech impairment only

1

Unilateral weakness

2

Duration of symptoms

10–59 minutes

1

≥ 60 minutes

2

Diabetes mellitus

Present

1

Interpretation

  • Score 0 to 3: low two-day stroke risk (1%)
  • Score 4 to 5: moderate two-day stroke risk (4%)
  • Score 6 to 7: high two-day stroke risk (8%)

High-risk imaging findings

Disposition [8][17]

Hospitalization should be considered for patients with suspected TIA within 72 hours of onset PLUS any of the following:

Treatment

General principles

  • There is no specific treatment for the TIA itself.
  • Therapeutic goals consist of preventing subsequent stroke (i.e., secondary prevention) and treatment of underlying conditions.
  • For primary prevention measures that decrease the likelihood of a first TIA, see “Prevention” in ischemic stroke.

Antithrombotic therapy for TIA [1][10][21]

  • Choice of agent should take the following into consideration:
    • Preventative pharmacotherapy the patient was taking at the time of the TIA event
    • TIA severity (and risk of subsequent ischemic stroke)
    • Suspected etiology
    • Patient comorbidities
  • Timing: within 24 hours (start as soon as safely possible after establishing ischemic diagnosis and ruling out hemorrhage) [22]
Initial stroke prevention therapy in TIA [1][10][21][23]
Preventative stroke medication prior to TIA event Stroke prevention therapy
None
  • Low-risk TIA: aspirin [1]
  • High-risk TIA : Consider DAPT for 21 days with aspirin AND clopidogrel in consultation with neurology. [1][23]
  • Known cardioembolic source or indication for anticoagulation : Initiate anticoagulation therapy.
Antiplatelet monotherapy
  • Consider changing to DAPT with aspirin AND clopidogrel in consultation with neurology. [1][23]
  • Known cardioembolic source or indication for anticoagulation : Initiate anticoagulation therapy and reassess the indication for continued antiplatelet therapy. [1]
Chronic anticoagulation
  • Ensure therapeutic dosing of anticoagulant.
  • Consider the risk versus benefit of adding antiplatelet monotherapy if underlying atherosclerosis is likely.

Avoid triple therapy (DAPT plus anticoagulation) because of the increased risk of hemorrhage. [1]

Long-term stroke prevention based on suspected etiology [1][10]

Therapy should be tailored to the suspected underlying etiology.

Management of other modifiable risk factors [1]

  • Diabetes screening and treatment
  • Obesity screening and lifestyle counseling
  • Physical activity counseling
  • Consider nutritionist consultation or assessment. [24]
  • Consider obstructive sleep apnea (OSA) screening. [10]
  • Smoking cessation and elimination/reduction of alcohol intake

Acute management checklist

A brain MRI is preferred for TIA evaluation but a head CT (without IV contrast) must be performed first and immediately if there is concern for hemorrhage or acute infarction requiring reperfusion therapy.

If there is evidence of an acute infarct on imaging, start immediate management for an acute ischemic stroke.

Prognosis

  • Increased risk of future ischemic stroke [3]
    • Within 2 days: ∼ 3–10%
    • Within 90 days: ∼ 9–17%

References

  1. Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association.
  2. Kernan WN, Ovbiagele B, Black HR et al. Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. Stroke. 2014; 45 (7): p.2160-2236. doi: 10.1161/STR.0000000000000024 . | Open in Read by QxMD
  3. Al-Khaled M, Eggers J. MRI findings and stroke risk in TIA patients with different symptom durations. Neurology. 2013; 80 (21): p.1920-1926. doi: 10.1212/wnl.0b013e318293e15f . | Open in Read by QxMD
  4. Johnston SC, Fayad PB, Gorelick PB, et al. Prevalence and knowledge of transient ischemic attack among US adults. Neurology. 2003; 60 (9): p.1429-1434. doi: 10.1212/01.wnl.0000063309.41867.0f . | Open in Read by QxMD
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