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Medication

Medication Summary

Pharmacologic management for transient ischemic attacks (TIAs) is aimed at reducing both short-term and long-term risk of stroke. In view of the high short-term risk of stroke after TIA, antithrombotic therapy should be initiated as soon as intracranial hemorrhage has been ruled out.

Class Summary

Antiplatelet agents inhibit platelet function by blocking cyclooxygenase and subsequent aggregation.

Aspirin (Anacin, Ascriptin, Ecotrin, Bufferin, Bayer Aspirin)

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Aspirin blocks prostaglandin synthetase action, and this, in turn, inhibits prostaglandin synthesis and prevents formation of platelet-aggregating thromboxane A2.

Aspirin 25 mg/dipyridamole 200 mg (Aggrenox)

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Combination aspirin-dipyridamole therapy has been shown to prevent cardiovascular events following TIAs. Each capsule contains 25 mg of aspirin and 200 mg of dipyridamole, for a daily total dose of 50 mg of aspirin and 400 mg of dipyridamole.

Aspirin irreversibly inhibits formation of cyclooxygenase, thus preventing formation of thromboxane A2, a platelet aggregator and vasoconstrictor. Platelet inhibition lasts for the life of a cell (approximately 10 days).

Dipyridamole is a platelet adhesion inhibitor that possibly inhibits red blood cell (RBC) uptake of adenosine, itself an inhibitor of platelet reactivity. In addition, it may inhibit phosphodiesterase activity, leading to increased cyclic 3′,5′-adenosine monophosphate within platelets and formation of the potent platelet activator thromboxane A2.

Clopidogrel (Plavix)

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Clopidogrel selectively inhibits the binding of adenosine diphosphate (ADP) to its platelet receptor and subsequent ADP-mediated activation of the glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation.

Dipyridamole (Persantine)

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Dipyridamole is administered to complement usual warfarin therapy. It inhibits platelet adhesion, which may inhibit adenosine uptake by RBCs. It may increase cyclic 3′,5′-adenosine monophosphate (cAMP) within platelets and formation of the potent platelet activator thromboxane A2. In addition, it may reduce the risk of stroke when used as monotherapy instead of aspirin.

Ticlopidine (Ticlid)

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Ticlopidine is a second-line antiplatelet therapy for patients who cannot tolerate or do not respond to aspirin therapy. In some circumstances, it can be an alternative to clopidogrel.

Class Summary

Controlled therapeutic inhibition of blood clotting by means of appropriate drugs (ie, anticoagulants) is indicated for prevention of ischemic stroke in patients with risk factors for thromboembolism, such as atrial fibrillation.

Warfarin (Coumadin)

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Warfarin interferes with hepatic synthesis of vitamin K−dependent coagulation factors. It is used for prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders.

Questions

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Sheehan OC, Merwick A, Kelly LA, Hannon N, Marnane M, Kyne L, et al. Diagnostic usefulness of the ABCD2 score to distinguish transient ischemic attack and minor ischemic stroke from noncerebrovascular events: the North Dublin TIA Study. Stroke. 2009 Nov. 40(11):3449-54. [QxMD MEDLINE Link].
Tsivgoulis G, Stamboulis E, Sharma VK, Heliopoulos I, Voumvourakis K, Teoh HL, et al. Multicenter external validation of the ABCD2 score in triaging TIA patients. Neurology. 2010 Apr 27. 74(17):1351-7. [QxMD MEDLINE Link]. [Full Text].
Asimos AW, Johnson AM, Rosamond WD, et al. A multicenter evaluation of the ABCD2 score's accuracy for predicting early ischemic stroke in admitted patients with transient ischemic attack. Ann Emerg Med. 2010 Feb. 55(2):201-210.e5. [QxMD MEDLINE Link]. [Full Text].
Chandratheva A, Geraghty OC, Luengo-Fernandez R, Rothwell PM. ABCD2 score predicts severity rather than risk of early recurrent events after transient ischemic attack. Stroke. 2010 May. 41(5):851-6. [QxMD MEDLINE Link]. [Full Text].
Stead LG, Suravaram S, Bellolio MF, Enduri S, Rabinstein A, Gilmore RM, et al. An assessment of the incremental value of the ABCD2 score in the emergency department evaluation of transient ischemic attack. Ann Emerg Med. 2011 Jan. 57(1):46-51. [QxMD MEDLINE Link].
Fothergill A, Christianson TJ, Brown RD Jr, Rabinstein AA. Validation and refinement of the ABCD2 score: a population-based analysis. Stroke. 2009 Aug. 40(8):2669-73. [QxMD MEDLINE Link]. [Full Text].
Amarenco P, Labreuche J, Lavallée PC, Meseguer E, Cabrejo L, Slaoui T, et al. Does ABCD2 score below 4 allow more time to evaluate patients with a transient ischemic attack?. Stroke. 2009 Sep. 40(9):3091-5. [QxMD MEDLINE Link].
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Donnan GA, Davis SM, Hill MD, Gladstone DJ. Patients with transient ischemic attack or minor stroke should be admitted to hospital: for. Stroke. 2006 Apr. 37(4):1137-8. [QxMD MEDLINE Link].
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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. 2007 Oct 20. 370(9596):1432-42. [QxMD MEDLINE Link].
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Torres Macho J, Peña Lillo G, Pérez Martínez D, González Mansilla A, Gámez Díez S, Mateo Alvarez S, et al. Outcomes of atherothrombotic transient ischemic attack and minor stroke in an emergency department: results of an outpatient management program. Ann Emerg Med. 2011 May. 57(5):510-6. [QxMD MEDLINE Link].
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Table 1. National Institutes of Health Stroke Scale

	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

Table 2. ABCD ² 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

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Author

Ashish Nanda, MD Assistant Professor of Neurology, Neurosurgery and Radiology, Stroke and Neurointerventional, Department of Neurology and Neurosurgery, Co-Director of Missouri Stroke Program, University of Missouri-Columbia School of Medicine

Ashish Nanda, MD is a member of the following medical societies: American Stroke Association, Society of NeuroInterventional Surgery, Society of Vascular and Interventional Neurology

Disclosure: Nothing to disclose.

Coauthor(s)

Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM Adjunct Associate Professor of Neurology, University of Missouri-Columbia School of Medicine; Medical Director of St Mary's Stroke Program, SSM Neurosciences Institute, SSM Health

Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

Chief Editor

Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

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 School of Medicine in New Orleans

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.

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

Lauren M Nentwich, MD Attending Physician, Department of Emergency Medicine, Boston Medical Center; Instructor, Department of Emergency Medicine, Boston University School of Medicine

Lauren M Nentwich is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Heart Association, Massachusetts Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Transient Ischemic Attack Medication

Medication Summary

Antiplatelet Agents

Class Summary

Aspirin (Anacin, Ascriptin, Ecotrin, Bufferin, Bayer Aspirin)

Aspirin (Anacin, Ascriptin, Ecotrin, Bufferin, Bayer Aspirin)

Aspirin 25 mg/dipyridamole 200 mg (Aggrenox)