Transient Ischemic Attack Medication
- Author: Joshua N Goldstein, MD, PhD, FAAEM; Chief Editor: Rick Kulkarni, MD more...
Medication Summary
Medical management is aimed at reducing both short- and long-term risk of stroke. Antithrombotic therapy should be initiated as soon as intracranial hemorrhage has been ruled out, given the high short-term risk of stroke following TIA.
Antiplatelet Agents
Class Summary
These agents inhibit platelet function by blocking cyclooxygenase and subsequent aggregation.
Aspirin (Anacin, Ascriptin, Ecotrin, Bufferin, Bayer Aspirin)
Aspirin blocks prostaglandin synthetase action, which, in turn, inhibits prostaglandin synthesis and prevents formation of platelet-aggregating thromboxane A2.
Aspirin 25 mg/dipyridamole 200 mg (Aggrenox)
This combination may be superior to aspirin alone in preventing cardiovascular events following TIAs. Aspirin irreversibly inhibits formation of cyclooxygenase, thus preventing formation of thromboxane A2, a platelet aggregator and vasoconstrictor. Platelet inhibition lasts for the life of a cell (approximately 10 d). Dipyridamole is a platelet adhesion inhibitor that possibly inhibits RBC uptake of adenosine, itself an inhibitor of platelet reactivity. In addition, it may inhibit phosphodiesterase activity leading to increased cyclic-3',5'-adenosine monophosphate within platelets and formation of the potent platelet activator thromboxane A2. Each capsule contains 25 mg aspirin and 200 mg dipyridamole, for a total of 50 mg aspirin and 400 mg dipyridamole to be given per day.
Clopidogrel (Plavix)
Clopidogrel selectively inhibits ADP binding to platelet receptor and subsequent ADP-mediated activation of glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation.
Dipyridamole (Persantine)
Dipyridamole is administered to complement usual warfarin therapy. It inhibits platelet adhesion, which may inhibit adenosine uptake by RBCs. It may increase cyclic-3',5'-AMP within platelets and formation of the potent platelet activator thromboxane A2. In addition, it may reduce the risk of stroke when used as monotherapy instead of aspirin.
Ticlopidine (Ticlid)
Ticlopidine is a second-line antiplatelet therapy for patients who cannot tolerate or do not respond to aspirin therapy. In some circumstances, it can be an alternative to clopidogrel.
Anticoagulant
Warfarin (Coumadin)
Warfarin interferes with hepatic synthesis of vitamin K-dependent coagulation factors. It is used for prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders.
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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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