Transient Ischemic Attack Workup
- Author: Joshua N Goldstein, MD, PhD, FAAEM; Chief Editor: Rick Kulkarni, MD more...
Approach Considerations
Ruling out metabolic or drug-induced etiologies for symptoms consistent with a transient ischemic attack (TIA) is important. Most importantly, a fingerstick blood glucose should be performed for hypoglycemia. Serum electrolytes should be measured for electrolyte derangements.
Emergent Tests
The following tests are considered emergent:
- Serum chemistry profile, including creatinine
- Coagulation studies
- Complete blood cell count
Urgent Tests
The following tests typically are helpful and often can be performed on an urgent basis:
- Erythrocyte sedimentation rate (ESR)
- Cardiac enzymes
- Lipid profile
Screening Tests for Hypercoagulable States
Screening for hypercoagulable states (particularly in younger patients with no known vascular risk factors) include the following[2] :
- Protein C, protein S, antithrombin III activities
- Activated protein C resistance/Factor V Leiden
- Fibrinogen
- D-Dimer
- Anticardiolipin antibody
- Lupus anticoagulant
- Homocysteine
- Prothrombin gene G20210A mutation
- Factor VIII
- Von Willebrand factor
- Plasminogen activator inhibitor-1
- Endogenous tissue plasminogen activator activity
History-Directed Tests
Additional laboratory tests, as needed and based on history, include the following:
- Syphilis serology
- Antiphospholipid antibodies
- Toxicology screens
- Hemoglobin electrophoresis
- Serum protein electrophoresis
- Cerebrospinal fluid examination
Brain Imaging
National recommendations for urgent evaluation of the patient with a transient ischemic attack (TIA) include imaging of the brain within 24 hours of symptom onset, preferably MRI with diffusion-weighted imaging (DWI), but if this is not available, then a CT scan should be obtained.[2, 15] The cerebral vasculature should be imaged urgently, preferably at the same time as the brain. Brain imaging can identify an area of ischemia in up to 25% of patients, and TIA mimics may be identified as well. Vessel imaging can identify a stenosis or occlusion that requires early intervention.
Noncontrast cranial CT scanning
The noncontrast cranial CT scan is widely and rapidly available and often serves as the initial imaging evaluation. It can aid in diagnosing the following:
- A new area of ischemia or infarction
- Old areas of ischemia
- Intracranial mass such as tumor
- Intracranial bleeding, such as subdural hematoma or intracerebral hemorrhage
Magnetic resonance imaging
MRI is more sensitive than CT for acute ischemia, infarction, previous intracranial bleeding, and other underlying lesions. MRI is less widely available on an acute basis than CT scan, however. The presence of ischemic lesions on an MRI appears to increase the short-term risk of stroke, highlighting its value in acute risk stratification.[16, 17, 18] In addition, a negative DWI image in concert with low-risk clinical features can mark those at minimal short-term stroke risk.[19] Recent data suggest that patients with DWI abnormalities, despite low ABCD2 scores, are at just as high a risk for stroke as patients with high ABCD2 scores but no DWI abnormalities.[20]
Electroencephalography
Electroencephalography (EEG) may be indicated to evaluate for seizure activity.
Vascular Imaging
Vascular imaging for TIA includes Doppler ultrasound, computed tomographic angiography (CTA), and MRA.
Doppler ultrasonography
Carotid Doppler ultrasonography of the neck can be used to identify patients in need of urgent surgical or endovascular therapy. Transcranial Doppler can be a complementary examination evaluating patency of cerebral vessels and collateral circulation.
Angiography
Computed tomographic angiography (CTA) is of increasing value in identifying occlusive disease in the cerebrovascular circulation. Magnetic resonance angiography (MRA) is another alternative for imaging vessels in both the brain and neck. Conventional angiography can be performed when the other modalities are unavailable or yield discordant results.
Cardiac Imaging and Monitoring
Transthoracic or transesophageal echocardiography (TTE/TEE) can evaluate for a cardioembolic source or for risk factors such as patent foramen ovale.
Twelve-lead electrocardiography should be performed as soon as possible after transient ischemic attack (TIA) and can evaluate for dysrhythmias such as atrial fibrillation.
Cardiac monitoring (inpatient telemetry or Holter monitor) is recommended as "useful" in patients without a clear diagnosis after initial brain imaging and electrocardiography.
Lumbar Puncture
Lumbar puncture (LP) may be indicated if subarachnoid hemorrhage, infectious etiology, or demyelinating disease is to be excluded.
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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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