History
A transient ischemic attack (TIA) may last only minutes, and symptoms often resolve before the patient presents to a clinician. Thus, historical questions should be addressed not just to the patient but also to family members, witnesses, and emergency medical services (EMS) personnel. Witnesses often perceive abnormalities that the patient cannot, such as changes in behavior, speech, gait, memory, and movement.
Significant medical history questions to elicit any risk factors for relevant underlying disease include questions about the following:
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Recent surgery (eg, carotid or cardiac)
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Previous strokes or TIAs
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Seizures
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Systemic or central nervous system (CNS) infections
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Use of illicit drugs
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Complete medication regimen, including all over-the-counter medications
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Comorbidities related to metabolic disorders, especially diabetes
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Known coagulopathy or family history of early clotting or thrombotic events
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History of arteritis
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Noninfectious necrotizing vasculitis, irradiation, and local trauma
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Thromboembolic risk factors (eg, carotid artery stenosis, venous or arterial thromboembolism, patent foramen ovale or atrial septal defect, atrial fibrillation, prior myocardial infarction, and left ventricular dysfunction)
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Other known cardiovascular disease
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History of migraine
Carefully investigate the 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.
Use these various resources to attempt to clarify when symptoms first occurred, how long they lasted, whether the patient recovered completely (ie, returned to baseline status), and if a pattern of escalating symptoms is present. For patients who woke up or are found with symptoms, the time they were last known to be normal should be documented.
If a patient has a history of associated trauma or cardiac symptoms, the differential diagnosis widens. Pertinent negative items (eg, lack of headache, lack of chest pain, and lack of eye pain) in the review of systems are also important.
Carotid or vertebral dissection can occur in association with both major and minor trauma. The patient may provide a history of blunt or torsion injury to the neck. An apparent association between cervical manipulation (as in chiropractic neck adjustment or massage therapy) and arterial dissections has been frequently reported. [17, 18]
Physical Examination
The goals of the physical examination are to uncover any neurologic deficits, to evaluate for underlying cardiovascular risk factors, and to seek any potential thrombotic or embolic source of the event. Global CNS depression and airway or cardiac compromise are not typically features of a TIA. In fact, the level of consciousness and neurologic examination findings are expected to be at the patient’s baseline.
Ideally, any neurologic deficits should be recorded with the aid of a formal and reproducible stroke scale, such as the National Institutes of Health Stroke Scale (NIHSS) (For additional information on this systematic assessment tool, see Stroke Scale). A stroke scale prompts the examiner to be thorough and allows different examiners to repeat the examination reliably during subsequent phases of the evaluation. Any neurologic abnormalities should suggest the diagnosis of stroke (or ongoing neurologic event) rather than TIA.
Identify signs of other active comorbidities, including infections (eg, sinusitis, mastoiditis, and meningitis) and vasculitides. The carotid arteries can be examined for pulse upstroke or bruit, and the neck can be examined for the presence of carotid endarterectomy scars.
Funduscopy can identify retinal plaques, retinal pigmentation, and optic disc margins. Pupil reaction to direct and consensual light exposure can be assessed.
In addition to performing standard auscultation, examine the chest for the presence of surgical scars, for the presence of a pacemaker or automatic implantable cardioverter-defibrillator (ICD), or for other clues that the patient may have a cardiac disorder and may be increased risk for a cardioembolic phenomenon.
Cardioembolic events are significant causes of TIAs. Assess for irregular rhythm or other unusual rhythms and rates, murmurs, or rubs that might suggest valvular disease, atrial-septal defects, or ventricular aneurysm (a source of mural thrombi). Check for splinter hemorrhages in the nail beds.
The following signs may be present in patients with cranial nerve dysfunction:
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Ocular dysmotility
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Forehead wrinkling asymmetry
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Incomplete eyelid closure
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Asymmetrical mouth retraction
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Loss of the nasolabial crease
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Swallowing difficulty
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Lateral tongue movement
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Weak shoulder shrugging
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Visual field deficits
The cerebellar system can be tested by assessing ocular movement, gait, and finger-to-nose and heel-to-knee movements, with an eye to signs of past-pointing and dystaxia, hypotonia, overshooting, gait dystaxia, and nystagmus. The speech and language system can be tested to assess for both aphasia and dysarthria. Mental status can be assessed formally (eg, with the Mini-Mental Status Examination or Quick Confusion Scale) or as part of the patient’s overall response to questions and interactions with the examiner.
Neurologic Examination
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. Subsets of the neurologic examination include the following:
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Cranial nerve testing
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Determination of somatic motor strength
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Somatic sensory testing
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Speech and language testing
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Assessment of the cerebellar system (be sure to watch the patient walk)
For somatic motor testing, test muscle stretch reflexes of the biceps, triceps, brachioradialis, patellar, and Achilles. In addition, inspect posture and look for tremors. Test the strength of the shoulder girdle, upper extremities, abdominal muscles, and lower extremities. Test passive movement of major joints to look for spasticity, clonus, and rigidity.
Stroke Scale
The National Institutes of Health Stroke Scale (NIHSS) (see Table 1 below) is used mostly by stroke teams for quantifying neurologic impairment. It enables rapid determination of the severity and possible location of the stroke. A patient’s score on the NIHSS is strongly associated with outcome, and it can help identify those patients who are likely to benefit from thrombolytic therapy and those who are at higher risk for developing hemorrhagic complications of thrombolytic use.
Table 1. National Institutes of Health Stroke Scale (Open Table in a new window)
|
Category |
Score - Description |
1a |
level of consciousness (LOC) |
0 Alert 1 Drowsy 2 Stuporous 3 Coma |
1b |
LOC questions (month, age) |
0 Answers both correctly 1 Answers 1 correctly 2 Incorrect on both |
1c |
LOC commands (open and close eyes, grip and release nonparetic hand) |
0 Obeys both correctly 1 Obeys 1 correctly 2 Incorrect on both |
2 |
Best gaze (follow finger) |
0 Normal 1 Partial gaze palsy 2 Forced deviation |
3 |
Best visual (visual fields) |
0 No visual loss 1 Partial hemianopia 2 Complete hemianopia 3 Bilateral hemianopia |
4 |
Facial palsy (show teeth, raise brows, squeeze eyes shut) |
0 Normal 1 Minor 2 Partial 3 Complete |
5 |
Motor arm left* (raise 90°, hold 10 seconds) |
0 No drift 1 Drift 2 Cannot resist gravity 3 No effort against gravity 4 No movement |
6 |
Motor arm right* (raise 90°, hold 10 seconds) |
0 No drift 1 Drift 2 Cannot resist gravity 3 No effort against gravity 4 No movement |
7 |
Motor leg left* (raise 30°, hold 5 seconds) |
0 No drift 1 Drift 2 Cannot resist gravity 3 No effort against gravity 4 No movement |
8 |
Motor leg right* (raise 30°, hold 5 seconds) |
0 No drift 1 Drift 2 Cannot resist gravity 3 No effort against gravity 4 No movement |
9 |
Limb ataxia (finger-nose, heel-shin) |
0 Absent 1 Present in 1 limb 2 Present in 2 limbs |
10 |
Sensory (pinprick to face, arm, leg) |
0 Normal 1 Partial loss 2 Severe loss |
11 |
Extinction/neglect (double simultaneous testing) |
0 No neglect 1 Partial neglect 2 Complete neglect |
12 |
Dysarthria (speech clarity to “mama, baseball, huckleberry, tip-top, fifty-fifty”) |
0 Normal articulation 1 Mild to moderate dysarthria 2 Near to unintelligible or worse |
13 |
Best language** (name items, describe pictures) |
0 No aphasia 1 Mild to moderate aphasia 2 Severe aphasia 3 Mute |
|
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 |
||
The NIHSS is easily used and focuses on the following 6 major areas of the neurologic examination:
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level of consciousness
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Visual function
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Motor function
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Sensation and neglect
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Cerebellar function
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Language
The NIHSS is a 42-point scale, with minor strokes usually being considered to result in a score lower than 5. An NIHSS score higher than 10 correlates with an 80% likelihood of visual flow deficits on angiography. Yet, discretion must be used in assessing the magnitude of the clinical deficit; for instance, if a patient’s only deficit is being mute, the NIHSS score will be 3. Additionally, the scale does not measure some deficits associated with posterior circulation strokes (eg, vertigo and ataxia).
Vital Signs and Overall Status
Initial vital signs should include the following:
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Temperature
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Blood pressure
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Heart rate and rhythm
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Respiratory rate and pattern
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Oxygen saturation
The examiner should assess the patient’s overall health and appearance, making an assessment of the following:
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Attentiveness
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Ability to interact with the examiner
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Language and memory skills
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Overall hydration status
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Development
Tables
|
Category |
Score - Description |
1a |
level of consciousness (LOC) |
0 Alert 1 Drowsy 2 Stuporous 3 Coma |
1b |
LOC questions (month, age) |
0 Answers both correctly 1 Answers 1 correctly 2 Incorrect on both |
1c |
LOC commands (open and close eyes, grip and release nonparetic hand) |
0 Obeys both correctly 1 Obeys 1 correctly 2 Incorrect on both |
2 |
Best gaze (follow finger) |
0 Normal 1 Partial gaze palsy 2 Forced deviation |
3 |
Best visual (visual fields) |
0 No visual loss 1 Partial hemianopia 2 Complete hemianopia 3 Bilateral hemianopia |
4 |
Facial palsy (show teeth, raise brows, squeeze eyes shut) |
0 Normal 1 Minor 2 Partial 3 Complete |
5 |
Motor arm left* (raise 90°, hold 10 seconds) |
0 No drift 1 Drift 2 Cannot resist gravity 3 No effort against gravity 4 No movement |
6 |
Motor arm right* (raise 90°, hold 10 seconds) |
0 No drift 1 Drift 2 Cannot resist gravity 3 No effort against gravity 4 No movement |
7 |
Motor leg left* (raise 30°, hold 5 seconds) |
0 No drift 1 Drift 2 Cannot resist gravity 3 No effort against gravity 4 No movement |
8 |
Motor leg right* (raise 30°, hold 5 seconds) |
0 No drift 1 Drift 2 Cannot resist gravity 3 No effort against gravity 4 No movement |
9 |
Limb ataxia (finger-nose, heel-shin) |
0 Absent 1 Present in 1 limb 2 Present in 2 limbs |
10 |
Sensory (pinprick to face, arm, leg) |
0 Normal 1 Partial loss 2 Severe loss |
11 |
Extinction/neglect (double simultaneous testing) |
0 No neglect 1 Partial neglect 2 Complete neglect |
12 |
Dysarthria (speech clarity to “mama, baseball, huckleberry, tip-top, fifty-fifty”) |
0 Normal articulation 1 Mild to moderate dysarthria 2 Near to unintelligible or worse |
13 |
Best language** (name items, describe pictures) |
0 No aphasia 1 Mild to moderate aphasia 2 Severe aphasia 3 Mute |
|
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: Systolic ≥140 mm Hg or diastolic ≥90 mm Hg |
1 point |
C: Clinical features |
|
Unilateral weakness with or without speech impairment |
2 points |
Speech impairment without unilateral weakness |
1 point |
D: Duration |
|
≥60 min |
2 points |
10-59 min |
1 point |
D: Diabetes |
1 point |
Total |
0-7 points |
