Transient Ischemic Attack
- Author: Joshua N Goldstein, MD, PhD, FAAEM; Chief Editor: Rick Kulkarni, MD more...
Background
A transient ischemic attack (TIA) is an acute episode of temporary neurologic dysfunction resulting from focal cerebral ischemia not associated with permanent cerebral infarction. The clinical symptoms of TIA typically last less than an hour, but prolonged episodes can occur. While the classical definition of TIA included symptoms lasting as long as 24 hours, advances in neuroimaging have suggested that many such cases represent minor strokes with resolved symptoms rather than true TIAs.
A group of cerebrovascular experts proposed a shift from the arbitrary time-based definition of TIA to a tissue-based definition in 2002 with a new definition for TIA as "a brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction."[1] This proposed new definition was well received and endorsed by many clinicians. The American Heart Association and American Stroke Association (AHA/ASA) 2009 Guidelines endorsed this new definition, modifying it with the omission of the phrase "typically less than one hour," as there is no time cutoff that reliably distinguishes whether a symptomatic ischemic event will result in tissue infarction.
The AHA/ASA-endorsed definition of TIA is as follows: Transient ischemic attack (TIA) is a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.[2]
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. 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. (See Clinical Presentation.)
Ruling out metabolic or drug-induced etiologies for symptoms consistent with a TIA is important. Most importantly, a fingerstick blood glucose should be checked for hypoglycemia. Serum electrolytes should be sent to investigate for electrolyte derangements. The following tests are considered emergent: serum chemistry profile, including creatinine; coagulation studies; and complete blood count. (See Workup.)
Initial assessment is aimed at excluding emergent conditions that can mimic a TIA, such as hypoglycemia, seizure, or intracranial hemorrhage. Laboratory studies, including CBC, coagulation studies, and electrolyte levels, should be obtained.[2, 3] (See Treatment and Management.) Antithrombotic therapy should be initiated as soon as intracranial hemorrhage has been ruled out (see Medication).
Pathophysiology
The transient ischemic attack (TIA) is characterized by a temporary reduction or cessation of cerebral blood flow in a specific neurovascular distribution that is due to low flow through a partially occluded vessel, an acute thromboembolic event, or stenosis of a small penetrating vessel.
Etiology
The transient ischemic attack (TIA) workup is focused on emergent/urgent risk stratification and management.
Numerous potential underlying causes can be readily identified, including the following:
- Atherosclerosis of carotid and vertebral arteries
- Embolic sources - Valvular disease, ventricular thrombus, and thrombus formation due to atrial fibrillation
- Arterial dissection
- Arteritis - Inflammation of the arteries occurring primarily in elderly persons, especially women; noninfectious necrotizing vasculitis (primary cause); drugs; irradiation; local trauma
- Sympathomimetic drugs (eg, cocaine)
- Mass lesions (eg, tumors, subdural hematomas) - Less frequently cause transient symptoms and more often result in progressive persistent symptoms
Causes of transient ischemic attack in children
TIA etiologies in children, which can differ from those in adults, include the following:
- Congenital heart disease with cerebral thromboembolism (most common)
- Drug abuse (eg, cocaine)
- Clotting disorders
- Central nervous system infection
- Neurofibromatosis
- Vasculitis
- Idiopathic progressive arteriopathy of childhood (moyamoya)
- Fibromuscular dysplasia
- Marfan disease
- Tuberous sclerosis
- Tumor
Epidemiology
Between 200,000 and 500,000 transient ischemic attacks (TIAs) are diagnosed annually in the United States.[4, 5] Emergency Department (ED) visits for TIAs occur at an approximate rate of 1.1 per 1,000 US population, and TIAs are diagnosed in 0.3% of ED visits.[6] TIA carries a particularly high short-term risk of stroke, and approximately 15% of diagnosed strokes are preceded by TIAs.
TIAs occur in about 150,000 patients per year in the United Kingdom.[7] The population incidence likely mirrors that of stroke.
The incidence of TIAs in blacks, 98 cases per 100,000 people, is higher than that in whites, 81 cases per 100,000 people. Controversy exists regarding whether race influences emergent workup following TIA.[8, 9]
The incidence of TIAs in men, 101 cases per 100,000 people, is significantly higher than that in women, 70 cases per 100,000 people.[10]
The incidence of TIAs increases with age, from 1-3 cases per 100,000 in those younger than 35 years to up to 1500 cases per 100,000 in those older than 85 years.[4] Fewer than 3% of all major cerebral infarcts occur in children. Pediatric strokes often can have quite different etiologies than adult strokes and tend to occur with less frequency.
Prognosis
With passive reporting, the early risk of stroke following transient ischemic attack (TIA) is approximately 4% at 2 days, 8% at 30 days, and 9% at 90 days.[11] When patients with TIA are followed prospectively, however, the incidence of stroke is as high as 11% at 7 days.[7]
Patients with TIAs have an increased risk of stroke and death from coronary artery disease (depending on risk factors in the study group, approximately 6-10% per year).
The probability that a person will have a stroke in the 5 years following a TIA is reported to be 24-29%.
Patient Education
It is essential that patients who are being discharged from the hospital first receive clear instruction to ensure understanding of the need for a complete and rapid workup through close follow-up care. The patient who has had a TIA needs to be educated about lifestyle modification and cardiovascular risk factors.
Also essential for patients is education on stroke symptoms, the need to call emergency services immediately if any of these symptoms occur, and the contact number for emergency services (911 in the United States).
Additionally, despite program efforts in public education, many patients still do not seek medical attention after experiencing TIA symptoms. A recent population-based study of patients suffering TIA or minor stroke found that 31% of all patients who experienced a recurrent stroke within 90 days of their first TIA or minor stroke did not seek medical attention after the initial event.[12] Public health professionals and physicians need to do more, such as promoting and participating in medical screening fairs and public outreach programs.
For excellent patient education resources, visit eMedicine's Stroke Center. In addition, see eMedicine's patient education article Transient Ischemic Attack (Mini-stroke).
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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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