eMedicine Specialties > Emergency Medicine > Neurology

Transient Ischemic Attack: Differential Diagnoses & Workup

Author: Joshua N Goldstein, MD, PhD, FAAEM, Assistant Professor of Surgery (Emergency Medicine), Harvard Medical School; Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Oct 23, 2009

Differential Diagnoses

Bell Palsy
Seizures in the Emergency Department
Headache, Migraine
Stroke, Hemorrhagic
Hypoglycemia
Stroke, Ischemic
Neoplasms, Brain
Subarachnoid Hemorrhage

Workup

Laboratory Studies

  • 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.
    • Emergency presentation
      • Serum chemistry profile including creatinine
      • Coagulation studies
      • Complete blood count
    • Typically helpful and can often be performed urgently
      • Erythrocyte sedimentation rate (ESR)
      • Cardiac enzymes 
      • Lipid profile
      • Screening for hypercoagulable states (particularly in patients younger than 50 y)
      • Levels of protein C and protein S
      • Antithrombin III level
      • Thrombin time
    • As needed based upon history
      • Syphilis serology
      • Antiphospholipid antibodies
      • Toxicology screens
      • Hemoglobin electrophoresis
      • Serum protein electrophoresis
      • Cerebrospinal fluid examination

Imaging Studies

National recommendations for urgent evaluation of the patient with a TIA include urgent or emergent imaging of the brain and cerebral vasculature. 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.

  • Brain imaging
    • Noncontrast cranial CT scan: This test is widely available and often recommended as the initial imaging evaluation. It can aid in diagnosing: 
      • 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 
    • MRI 
      • MRI is more sensitive for acute ischemia, infarction, previous intracranial bleeding, and other underlying lesions than CT. 
      • The presence of ischemic lesions on MRI appears to increase the short-term risk of stroke, highlighting its potential value in acute risk stratification.9,10
      • However, this study is less widely available on an acute basis than CT scan.
  • Vascular imaging 
    • Carotid Doppler ultrasonography of the neck can 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.
    • 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 above modalities are unavailable or yield discordant results.
  • Cardiac imaging: Transthoracic or transesophageal echocardiography (TTE/TEE) can evaluate for a cardioembolic source or for risk factors such as patent foramen ovale.

Other Tests

  • 12-Lead electrocardiography can evaluate for dysrhythmias such as atrial fibrillation.
  • Lumbar puncture (LP) may be indicated if subarachnoid hemorrhage, infectious etiology, or demyelinating disease is to be excluded.
  • Electroencephalography (EEG) may be indicated to evaluate for seizure activity.

More on Transient Ischemic Attack

Overview: Transient Ischemic Attack
Differential Diagnoses & Workup: Transient Ischemic Attack
Treatment & Medication: Transient Ischemic Attack
Follow-up: Transient Ischemic Attack
References
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References

  1. Kleindorfer D, Panagos P, Pancioli A, et al. Incidence and short-term prognosis of transient ischemic attack in a population-based study. Stroke. Apr 2005;36(4):720-3. [Medline]. [Full Text].

  2. Edlow JA, Kim S, Pelletier AJ, et al. National study on emergency department visits for transient ischemic attack, 1992-2001. Acad Emerg Med. Jun 2006;13(6):666-72. [Medline].

  3. [Best Evidence] Giles MF, Rothwell PM. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. Dec 2007;6(12):1063-72. [Medline].

  4. Johnston SC, Gress DR, Browner WS, et al. Short-term prognosis after emergency department diagnosis of TIA. JAMA. Dec 13 2000;284(22):2901-6. [Medline].

  5. [Best Evidence] Wu CM, McLaughlin K, Lorenzetti DL, et al. Early risk of stroke after transient ischemic attack: a systematic review and meta-analysis. Arch Intern Med. Dec 10 2007;167(22):2417-22. [Medline].

  6. Jacobs BS, Birbeck G, Mullard AJ, et al. Quality of hospital care in African American and white patients with ischemic stroke and TIA. Neurology. Mar 28 2006;66(6):809-14. [Medline].

  7. White H, Boden-Albala B, Wang C, et al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the Northern Manhattan Study. Circulation. Mar 15 2005;111(10):1327-31. [Medline]. [Full Text].

  8. Bots ML, van der Wilk EC, Koudstaal PJ, et al. Transient neurological attacks in the general population. Prevalence, risk factors, and clinical relevance. Stroke. Apr 1997;28(4):768-73. [Medline].

  9. Redgrave JN, Schulz UG, Briley D, et al. Presence of acute ischaemic lesions on diffusion-weighted imaging is associated with clinical predictors of early risk of stroke after transient ischaemic attack. Cerebrovasc Dis. 2007;24(1):86-90. [Medline].

  10. Prabhakaran S, Chong JY, Sacco RL. Impact of abnormal diffusion-weighted imaging results on short-term outcome following transient ischemic attack. Arch Neurol. Aug 2007;64(8):1105-9. [Medline].

  11. Schwamm LH, Pancioli A, Acker JE 3rd, et al. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association's Task Force on the Development of Stroke Systems. Stroke. Mar 2005;36(3):690-703. [Medline].

  12. Adams HP Jr, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association. Stroke. Apr 2003;34(4):1056-83. [Medline].

  13. [Best Evidence] Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. Jan 27 2007;369(9558):283-92. [Medline].

  14. Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke. Feb 2006;37(2):577-617. [Medline].

  15. [Best Evidence] Halkes PH, van Gijn J, Kappelle LJ, et al. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial. Lancet. May 20 2006;367(9523):1665-73. [Medline].

  16. Donnan GA, Davis SM, Hill MD, et al. Patients with transient ischemic attack or minor stroke should be admitted to hospital: for. Stroke. Apr 2006;37(4):1137-8. [Medline].

  17. Lindley RI. Patients with transient ischemic attack do not need to be admitted to hospital for urgent evaluation and treatment: against. Stroke. Apr 2006;37(4):1139-40. [Medline].

  18. Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. Oct 20 2007;370(9596):1432-42. [Medline].

  19. Lavallee PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol. Nov 2007;6(11):953-60. [Medline].

  20. Giles MF, Rothwell PM. Substantial underestimation of the need for outpatient services for TIA and minor stroke. Age Ageing. Nov 2007;36(6):676-80. [Medline].

  21. Johnston SC, Nguyen-Huynh MN, Schwarz ME, et al. National Stroke Association guidelines for the management of transient ischemic attacks. Ann Neurol. Sep 2006;60(3):301-13. [Medline].

  22. Albers GW. A review of published TIA treatment recommendations. Neurology. Apr 27 2004;62(8 Suppl 6):S26-8. [Medline].

  23. [Best Evidence] Ross MA, Compton S, Medado P, et al. An emergency department diagnostic protocol for patients with transient ischemic attack: a randomized controlled trial. Ann Emerg Med. Aug 2007;50(2):109-19. [Medline].

  24. Bray JE, Coughlan K, Bladin C. Can the ABCD Score be dichotomised to identify high-risk patients with transient ischaemic attack in the emergency department?. Emerg Med J. Feb 2007;24(2):92-5. [Medline].

  25. [Best Evidence] Fothergill A, Christianson TJ, Brown RD Jr, Rabinstein AA. Validation and refinement of the ABCD2 score: a population-based analysis. Stroke. Aug 2009;40(8):2669-73. [Medline].

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Further Reading

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Keywords

transient ischemic attack, TIA, temporary and focal loss of cerebral function, cerebral blood flow reduction, stroke, ischemic stroke, carotid artery atherosclerotic disease, vertebral artery atherosclerotic disease, hypertension, hypotension, impending stroke, atherosclerotic disease, coronary artery disease, carotid artery dissection, vertebral artery dissection, necrotizing vasculitis

vertebral artery stenosis, carotid artery stenosis, cerebral embolism, valvular heart disease, ventricular thrombus, atrial fibrillation, arterial dissection, arteritis, cocaine abuse, subdural hematomas, congenital heart disease, cerebral thromboembolism, clotting disorders, CNS infection, vasculitis, idiopathic progressive arteriopathy of childhood, moyamoya, fibromuscular dysplasia, Marfan disease, tuberous sclerosis, tumor, neurofibromatosis, carotid endarterectomy scars, pacemaker, atrioseptal defects, ventricular aneurysm, cranial nerve dysfunction, nodular cranial arteries

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Contributor Information and Disclosures

Author

Joshua N Goldstein, MD, PhD, FAAEM, Assistant Professor of Surgery (Emergency Medicine), Harvard Medical School; Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
Joshua N Goldstein, MD, PhD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Stroke Association, and Society for Academic Emergency Medicine
Disclosure: CSL Behring Consulting fee Consulting; Genentech Consulting fee Consulting

Medical Editor

Peter MC DeBlieux, MD, Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University Health Sciences Center
Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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