eMedicine Specialties > Emergency Medicine > Neurology

Transient Ischemic Attack: Follow-up

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

Updated: Nov 17, 2009

Follow-up

Further Inpatient Care

While controversy exists regarding the need for admission, there is no controversy regarding the need for urgent evaluation, risk stratification, and initiation of stroke prevention therapy.24,25,1

When one community implemented a strategy to ensure patients were seen within an average of 1 day, compared with an average of 3 days, the 90-day stroke risk fell from 10% to 2%.26 Another initiated a program to admit patients to a "rapid evaluation unit," which dropped the 90-day stroke risk from 9.7% to 4.7%.27 Others have suggested similar benefits from rapid followup.28

The availability of local resources determines whether this urgent evaluation should occur as an inpatient, in an ED observation unit, or in rapid followup. In order to determine appropriate disposition, the emergency physician should determine necessary workup, then discuss with the neurologist or primary care doctor how best to ensure this occurs promptly.29

One randomized controlled trial of an emergency department diagnostic protocol found that they could reduce cost, length of stay, and provide appropriate risk stratification by performing this workup in an ED observation unit (with neurology consultation) rather than in an inpatient unit.30  

A number of patients present to the ED with a "transient neurological disturbance" that does not represent a true TIA, and these can be difficult to distinguish for the busy emergency practitioner. In addition, an emergent and comprehensive workup of all those with "possible TIA" may not be the most cost-effective or appropriate use of limited local resources. The emergency practitioner should use appropriate risk stratification to ensure that emergent diagnostic and therapeutic interventions are targeted to the highest risk patients. A number of risk stratification scores are available to assist in this task, but the most widely validated is the ABCD2 score.31,32,15  

ABCD2 Score

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Table
A: Age >601 point
B: Blood pressure >140/90 mm Hg1 point
C: Clinical features 
  Unilateral weakness2 points
  Speech disturbance without weakness1 point
D: Duration 
 >60 minutes2 points
  10-59 minutes1 point
D: Diabetes1 point
Total0-7 points
A: Age >601 point
B: Blood pressure >140/90 mm Hg1 point
C: Clinical features 
  Unilateral weakness2 points
  Speech disturbance without weakness1 point
D: Duration 
 >60 minutes2 points
  10-59 minutes1 point
D: Diabetes1 point
Total0-7 points

Individuals with an ABCD2 score higher than 6 had an 8% risk of stroke within 2 days, while those with an ABCD2 score less than 4 had a 1% risk of stroke within 2 days. Some of these patients with lower scores may well have non-TIA events rather than true TIAs.33 It has been proposed that this scoring system can be used to risk-stratify ED patients for emergent workup.31 Finally, abnormalities on brain imaging can highlight those at increased risk and should also be taken into consideration.

Some groups have noted that the short-term stroke risk after TIA can be worrisome even in those with a low ABCD2 scores.34,35

The American Heart Association1 comments "It is reasonable to hospitalize patients with TIA if they present within 72 hours of the event and any of the following criteria are present:"

  • ABCD2 score of 3 (Class IIa, level of Evidence C)
  • ABCD2 score of 0 to 2 and uncertainty that diagnostic workup can be completed within 2 days as an outpatient (Class IIa, level of Evidence C)
  • ABCD2 score of 0 to 2 and other evidence that indicates the patient's event was caused by focal ischemia (Class IIa, level of Evidence C)

Further Outpatient Care

  • Patients selected for outpatient care should have a clear follow-up plan and stroke prevention initiated as above, including antiplatelet medication and risk factor modification.
  • Patients with TIA and ipsilateral carotid artery stenosis may be candidates for urgent (<2 wk) carotid endarterectomy. In certain patients, carotid artery stenting is a reasonable alternative. This can be discussed acutely or rapid follow-up arranged.
  • Patients with symptoms attributable to extracranial vertebral stenosis may be candidates for endovascular treatment, and again this should be arranged rapidly if available.

Inpatient & Outpatient Medications

  • Antiplatelet agents should typically be initiated as soon as intracranial bleeding is ruled out. As above, the agent to be used varies with the patient and the specific indication.
  • Antihypertensive control for those with hypertension
  • Lipid control, potentially including a statin agent
  • Blood glucose control for those with diabetes
  • A smoking cessation strategy, which may include medication, should be initiated.
  • Heavy drinkers should eliminate or reduce alcohol consumption.
  • Weight loss if overweight
  • Exercise

Prognosis

  • With passive reporting, the early risk of stroke following TIA is approximately 4% at 2 days, 8% at 30 days, and 9% at 90 days.7 However, when patients with TIA are followed prospectively, the incidence of stroke is as high as 11% at 7 days.5
  • 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).
  • Probability of stroke in the 5 years following a TIA is reported to be 24-29%.

Patient Education

  • For patients to be discharged, make sure they understand the need for a complete and rapid workup through close follow-up care.
  • Education regarding lifestyle modification and cardiovascular risk factors is essential.
  • Education regarding stroke symptoms, the need to call emergency services immediately, and the contact number for emergency services (911 in the United States) is essential.
  • For excellent patient education resources, visit eMedicine's Stroke Center. Also, see eMedicine's patient education article Transient Ischemic Attack (Mini-stroke).

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose an emergent alternate condition, such as brain tumor or intracranial hemorrhage
  • Failure to ensure an expedited workup and initiation of stroke prevention strategies, including antiplatelet agents, given the high short-term risk of stroke
 


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. [Guideline] Easton JD, Saver JL, Albers GW, Alberts MJ, Chaturvedi S, Feldmann E. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke. Jun 2009;40(6):2276-93. [Medline].

  2. 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].

  3. Johnston SC, Fayad PB, Gorelick PB, Hanley DF, Shwayder P, van Husen D. Prevalence and knowledge of transient ischemic attack among US adults. Neurology. May 13 2003;60(9):1429-34. [Medline].

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

  5. [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].

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

  7. [Best Evidence] Wu CM, McLaughlin K, Lorenzetti DL, Hill MD, Manns BJ, Ghali WA. 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].

  8. 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].

  9. 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].

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

  11. Kleindorfer D, Panagos P, Pancioli A, Khoury J, Kissela B, Woo D. Incidence and short-term prognosis of transient ischemic attack in a population-based study. Stroke. Apr 2005;36(4):720-3. [Medline].

  12. Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976). Feb 15 2008;33(4 Suppl):S176-83. [Medline].

  13. [Guideline] National Institute for Health and Clinical Excellence (NICE) Stroke Guidelines. Accessed November 2009. [Full Text].

  14. Redgrave JN, Schulz UG, Briley D, Meagher T, Rothwell PM. 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].

  15. 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].

  16. Asimos AW, Rosamond WD, Johnson AM, Price MF, Rose KM, Murphy CV. Early diffusion weighted MRI as a negative predictor for disabling stroke after ABCD2 score risk categorization in transient ischemic attack patients. Stroke. Oct 2009;40(10):3252-7. [Medline].

  17. 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].

  18. 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].

  19. [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].

  20. Halliday AW, Lees T, Kamugasha D, Grant R, Hoffman A, Rothwell PM. Waiting times for carotid endarterectomy in UK: observational study. BMJ. 2009;338:b1847. [Medline]. [Full Text].

  21. Gladstone DJ, Oh J, Fang J, Lindsay P, Tu JV, Silver FL. Urgency of carotid endarterectomy for secondary stroke prevention: results from the Registry of the Canadian Stroke Network. Stroke. Aug 2009;40(8):2776-82. [Medline].

  22. 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].

  23. [Best Evidence] Halkes PH, van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A. 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].

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

  25. 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].

  26. 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].

  27. Wu CM, Manns BJ, Hill MD, Ghali WA, Donaldson C, Buchan AM. Rapid evaluation after high-risk TIA is associated with lower stroke risk. Can J Neurol Sci. Jul 2009;36(4):450-5. [Medline].

  28. 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].

  29. 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].

  30. [Best Evidence] Ross MA, Compton S, Medado P, Fitzgerald M, Kilanowski P, O'Neil BJ. 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].

  31. 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].

  32. 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].

  33. Sheehan OC, Merwick A, Kelly LA, Hannon N, Marnane M, Kyne L. Diagnostic usefulness of the ABCD2 score to distinguish transient ischemic attack and minor ischemic stroke from noncerebrovascular events: the North Dublin TIA Study. Stroke. Nov 2009;40(11):3449-54. [Medline].

  34. [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].

  35. Amarenco P, Labreuche J, Lavallee PC, Meseguer E, Cabrejo L, Slaoui T. Does ABCD2 score below 4 allow more time to evaluate patients with a transient ischemic attack?. Stroke. Sep 2009;40(9):3091-5. [Medline].

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

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Further Reading

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Keywords

transient ischemic attack, TIA, TIA symptoms, TIA causes, TIA treatment, stroke, mini stroke, ischemic stroke, carotid artery atherosclerotic disease, vertebral artery atherosclerotic disease, brain attack, hypertension, hypotension, arteritis

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Contributor Information and Disclosures

Author

Joshua N Goldstein, MD, PhD, FAAEM, Assistant Professor, 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, Neurocritical Care Society, 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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