eMedicine Specialties > Emergency Medicine > Neurology
Transient Ischemic Attack: Follow-up
Updated: Oct 23, 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.16,17
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%.18 Others have suggested similar benefits from rapid followup.19
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.20
National guidelines recommend that an urgent workup include the following:21,22
- Laboratory studies as above
- ECG
- Brain imaging
- Doppler ultrasonography
- Potentially, transthoracic echocardiography
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 ABCD (or ABCD2) score.24,21,10
ABCD2 Score
Open table in new window
Table
| A: Age ³60 | 1 point |
| B: Blood pressure ³140/90 mm Hg | 1 point |
| C: Clinical features | |
| Unilateral weakness | 2 points |
| Speech disturbance without weakness | 1 point |
| D: Duration | |
| ³60 minutes | 2 points |
| 10-59 minutes | 1 point |
| D: Diabetes | 1 point |
| Total | 0-7 points |
| A: Age ³60 | 1 point |
| B: Blood pressure ³140/90 mm Hg | 1 point |
| C: Clinical features | |
| Unilateral weakness | 2 points |
| Speech disturbance without weakness | 1 point |
| D: Duration | |
| ³60 minutes | 2 points |
| 10-59 minutes | 1 point |
| D: Diabetes | 1 point |
| Total | 0-7 points |
Individuals with an ABCD score higher than 6 had an 8% risk of stroke within 2 days, while those with an ABCD score less than 4 had a 1% risk of stroke within 2 days. It has been proposed that this scoring system can be used to risk-stratify ED patients for emergent workup.24 Finally, abnormalities on brain imaging can highlight those at increased risk and should also be taken into consideration.
In a population-based analysis from the Mayo Clinic, Fothergill et al found that, although ABCD2 scores greater than 4 had a statistically significant predictive value for future stroke, a substantial proportion of strokes within 7 days after a transient ischemic attack (9 of 36 cases [25%]) occurred in patients with low or intermediate risk scores (≤4). Including a history of hypertension and hyperglycemia on presentation increased the sensitivity of the score for identifying patients who had a stroke within 7 days.25
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.5 However, when patients with TIA are followed prospectively, the incidence of stroke is as high as 11% at 7 days.3
- 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
The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Jerome FX Naradzay, MD, to the development and writing of this article.
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 |
| « Previous Page |
References
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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].
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Further Reading
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
