Transient Ischemic Attack Clinical Presentation
- Author: Joshua N Goldstein, MD, PhD, FAAEM; Chief Editor: Rick Kulkarni, MD more...
History
A transient ischemic attack (TIA) may last only minutes, and symptoms often resolve before the patient presents to a clinician. Thus, historical questions should be addressed not just to the patient but also to family members, witnesses, and emergency medical services (EMS) personnel. Witnesses often perceive abnormalities that the patient cannot, such as changes in behavior, speech, gait, memory, and movement.
Significant medical history questions to elicit any risk factors for relevant underlying disease include questions about the following:
- Recent surgery (eg, carotid, cardiac)
- Previous strokes
- Seizures
- CNS infections
- Use of illicit drugs
- Complete medication regimen
- Comorbidities related to metabolic disorders, especially diabetes
- Known coagulopathy
- History of arteritis
- Noninfectious necrotizing vasculitis, drugs, irradiation, and local trauma
- Thromboembolic risk factors such as carotid artery stenosis, venous or arterial thromboembolism, patent foramen ovale, atrial fibrillation, prior myocardial infarction, or left ventricular dysfunction
- Other known cardiovascular disease
Carefully investigate onset, duration, fluctuation, and intensity of symptoms. Reviewing the patient's medical record is extremely important for identifying deficits from previous strokes, seizures, or cardiac events. The primary care physician can be a reliable resource for insights into previous episodes and workup.
Use these various resources to attempt to clarify when symptoms first occurred, how long they lasted, whether the patient recovered completely (ie, returned to baseline status), and if a pattern of escalating symptoms is present. For those who woke up or are found with symptoms, the time last known to be normal should be documented.
If a patient has a history of associated trauma or cardiac symptoms, the differential diagnosis widens. Pertinent negative items (eg, lack of headache, lack of chest pain, lack of eye pain) in the review of systems also are important.
Carotid or vertebral dissection can occur in association with both major and minor trauma. The patient may provide a history of blunt or torsion injury to the neck. Controversy exists regarding whether chiropractic manipulation or massage therapy increases the risk of arterial dissection.[13]
Physical Examination
The goal of the physical examination is to carefully uncover any neurologic deficits, evaluate for underlying cardiovascular risk factors, and seek any potential thrombotic or embolic source of the event.
Ideally, any neurologic deficits should be recorded with the aid of a formal and reproducible stroke scale, such as the National Institutes of Health Stroke Scale (NIHSS) (For additional information on this systematic assessment tool, please see Stroke Scale, below). A stroke scale prompts the examiner to be thorough and allows different examiners to reliably repeat the examination during subsequent phases of the evaluation. Any neurologic abnormalities should suggest the diagnosis of stroke (or ongoing neurologic event) rather than TIA.
Identify signs of other active comorbidities, including infections (eg, sinusitis, mastoiditis, meningitis) and vasculidities. Carotid arteries can be examined for pulse upstroke, bruit, and the presence of carotid endarterectomy scars.
Funduscopy can identify retinal plaques, retinal pigmentation, and optic disc margins. Pupil reaction to direct and consensual light exposure can be assessed.
In addition to performing standard auscultation, examine the chest for the presence of surgical scars, for the presence of a pacemaker/automatic implantable cardioverter defibrillator (AICD), or for other clues that the patient may have a cardiac disorder and increased risk of a cardioembolic phenomenon.
Cardioembolic events are significant causes of TIAs. Identify the rhythm for irregularity or other unusual rhythms and rates, murmurs, or rubs that might suggest valvular disease, atrioseptal defects, or ventricular aneurysm (a source of mural thrombi).
The following signs may be present with cranial nerve dysfunction:
- Ocular dysmotility
- Forehead wrinkling asymmetry
- Incomplete eyelid closure
- Asymmetrical mouth retraction
- Loss of the nasolabial crease
- Swallowing difficulty
- Lateral tongue movement
- Weak shoulder shrugging
- Visual field deficits
The cerebellar system can be tested by assessing ocular movement, gait, and finger-to-nose and heel-to-knee movements, looking for signs of past-pointing and dystaxia, hypotonia, overshooting, gait dystaxia, and nystagmus.
The speech and language system can be tested to assess for both aphasia and dysarthria.
Neurologic Examination
A neurologic examination is the foundation of the TIA evaluation and should focus in particular on the neurovascular distribution suggested by the patient’s symptoms. Subsets of the neurologic examination include the following:
- Cranial nerve testing
- Somatic motor strength
- Somatic sensory testing
- Speech and language testing
- Cerebellar system (be sure to see the patient walk)
Mental Status Assessment
Mental status can be assessed formally (Mini-Mental Status Examination, Quick Confusion Scale) or as part of the patient's overall response to questions and interactions with the examiner.
Somatic Motor Testing
Test muscle stretch reflexes of the biceps, triceps, brachioradialis, patellar, and Achilles. In addition, inspect posture and the presence of tremors.
Test the strength of the shoulder girdle, upper extremities, abdominal muscles, and lower extremities, and test passive movement of major joints to look for spasticity, clonus, and rigidity.
Stroke Scale
The National Institutes of Health Stroke Scale (NIHSS) (see Table 1, below) is used mostly by stroke teams for quantifying neurological impairment. It enables the consultant to rapidly determine the severity and possible location of the stroke. A patient's score on the NIHSS is strongly associated with outcome, and it can help to identify those patients who are likely to benefit from thrombolytic therapy and those who are at higher risk of developing hemorrhagic complications of thrombolytic use.
This scale is easily used and focuses on the following 6 major areas of the neurologic examination:
- level of consciousness
- Visual function
- Motor function
- Sensation and neglect
- Cerebellar function
- Language
The NIHSS is a 42-point scale, with minor strokes usually being considered to have a score less than 5. An NIHSS score greater than 10 correlates with an 80% likelihood of visual flow deficits on angiography. Yet, discretion must be used in assessing the magnitude of the clinical deficit; for instance, if a patient's only deficit is being mute, the NIHSS score will be 3. Additionally, the scale does not measure some deficits associated with posterior circulation strokes (ie, vertigo, ataxia).
Table 1. NIH Stroke Scale (Open Table in a new window)
| Category | Description | Score | |
| 1a | level of consciousness (LOC) | Alert Drowsy Stuporous Coma | 0 1 2 3 |
| 1b | LOC questions (month, age) | Answers both correctly Answers 1 correctly Incorrect on both | 0 1 2 |
| 1c | Answers both correctly Answers 1 correctly Incorrect on both | Obeys both correctly Obeys 1 correctly Incorrect on both | 0 1 2 |
| 2 | Best gaze (follow finger) | Normal Partial gaze palsy Forced deviation | 0 1 2 |
| 3 | Best visual (visual fields) | No visual loss Partial hemianopia Complete hemianopia Bilateral hemianopia | 0 1 2 3 |
| 4 | Facial palsy (show teeth, raise brows, squeeze eyes shut) | Normal Minor Partial Complete | 0 1 2 3 |
| 5 | Motor arm left* (raise 90°, hold 10 seconds) | No drift Drift Cannot resist gravity No effort against gravity No movement | 0 1 2 3 4 |
| 6 | Motor arm right* (raise 90°, hold 10 seconds) | No drift Drift Cannot resist gravity No effort against gravity No movement | 0 1 2 3 4 |
| 7 | Motor leg left* (raise 30°, hold 5 seconds) | No drift Drift Cannot resist gravity No effort against gravity No movement | 0 1 2 3 4 |
| 8 | Motor leg right* (raise 30°, hold 5 seconds) | No drift Drift Cannot resist gravity No effort against gravity No movement | 0 1 2 3 4 |
| 9 | Limb ataxia (finger-nose, heel-shin) | Absent Present in 1 limb Present in 2 limbs | 0 1 2 |
| 10 | Sensory (pinprick to face, arm, leg) | Normal Partial loss Severe loss | 0 1 2 |
| 11 | Extinction/neglect (double simultaneous testing) | No neglect Partial neglect Complete neglect | 0 1 2 |
| 12 | Dysarthria (speech clarity to "mama, baseball, huckleberry, tip-top, fifty-fifty") | Normal articulation Mild to moderate dysarthria Near to unintelligible or worse | 0 1 2 |
| 13 | Best language** (name items, describe pictures) | No aphasia Mild to moderate aphasia Severe aphasia Mute | 0 1 2 3 |
| Total | - | 0-42 | |
| * For limbs with amputation, joint fusion, etc, score 9 and explain. ** For intubation or other physical barriers to speech, score 9 and explain. Do not add 9 to the total score. | |||
Vital Signs
Initial vital signs should include the following:
- Temperature
- Blood pressure
- Heart rate and rhythm
- Respiratory rate and pattern
- Oxygen saturation
The examiner should assess the patient's overall health and appearance, making an assessment of the following:
- Attentiveness
- Ability to interact with the examiner
- Language and memory skills
- Overall hydration status
- Development
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| Category | Description | Score | |
| 1a | level of consciousness (LOC) | Alert Drowsy Stuporous Coma | 0 1 2 3 |
| 1b | LOC questions (month, age) | Answers both correctly Answers 1 correctly Incorrect on both | 0 1 2 |
| 1c | Answers both correctly Answers 1 correctly Incorrect on both | Obeys both correctly Obeys 1 correctly Incorrect on both | 0 1 2 |
| 2 | Best gaze (follow finger) | Normal Partial gaze palsy Forced deviation | 0 1 2 |
| 3 | Best visual (visual fields) | No visual loss Partial hemianopia Complete hemianopia Bilateral hemianopia | 0 1 2 3 |
| 4 | Facial palsy (show teeth, raise brows, squeeze eyes shut) | Normal Minor Partial Complete | 0 1 2 3 |
| 5 | Motor arm left* (raise 90°, hold 10 seconds) | No drift Drift Cannot resist gravity No effort against gravity No movement | 0 1 2 3 4 |
| 6 | Motor arm right* (raise 90°, hold 10 seconds) | No drift Drift Cannot resist gravity No effort against gravity No movement | 0 1 2 3 4 |
| 7 | Motor leg left* (raise 30°, hold 5 seconds) | No drift Drift Cannot resist gravity No effort against gravity No movement | 0 1 2 3 4 |
| 8 | Motor leg right* (raise 30°, hold 5 seconds) | No drift Drift Cannot resist gravity No effort against gravity No movement | 0 1 2 3 4 |
| 9 | Limb ataxia (finger-nose, heel-shin) | Absent Present in 1 limb Present in 2 limbs | 0 1 2 |
| 10 | Sensory (pinprick to face, arm, leg) | Normal Partial loss Severe loss | 0 1 2 |
| 11 | Extinction/neglect (double simultaneous testing) | No neglect Partial neglect Complete neglect | 0 1 2 |
| 12 | Dysarthria (speech clarity to "mama, baseball, huckleberry, tip-top, fifty-fifty") | Normal articulation Mild to moderate dysarthria Near to unintelligible or worse | 0 1 2 |
| 13 | Best language** (name items, describe pictures) | No aphasia Mild to moderate aphasia Severe aphasia Mute | 0 1 2 3 |
| Total | - | 0-42 | |
| * For limbs with amputation, joint fusion, etc, score 9 and explain. ** For intubation or other physical barriers to speech, score 9 and explain. Do not add 9 to the total score. | |||
| A: Age ≥60 years | 1 point |
| B: Blood pressure ≥140/90 mm Hg | 1 point |
| C: Clinical features | |
| Unilateral weakness | 2 points |
| Speech disturbance without weakness | 1 point |
| D: Duration | |
| ≥60 minutes | 2 points |
| 10-59 minutes | 1 point |
| D: Diabetes | 1 point |
| Total | 0-7 points |
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