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Transient Ischemic Attack – Spoon-Feed Version

August 17, 2020

Written by Alex Chen, MD

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We frequently encounter transient ischemic attack (TIA) in the ED. Here is what you need to know.

Why does this matter?
Up to one quarter of all strokes are preceded by a TIA. Recognition and treatment drastically reduces this risk.

TIA in brief

  1. TIA used to be defined by time-frame (symptoms lasting <24h, typically <1h); newer definitions are based on imaging results (negative imaging for ischemia = TIA).

  2. Diffusion-weighted imaging (DWI) MRI of the brain is the modality of choice and should be performed immediately if available. Perfusion-weighted imaging may add increased sensitivity if DWI is negative and suspicion remains high.

  3. Assess intracranial and extracranial arteries with noninvasive imaging (carotid ultrasound, CT angiography, MR angiography). Consider referral for carotid endarterectomy or stenting in patients with ipsilateral internal carotid artery stenosis >50%.

  4. As soon as possible after onset of symptoms, patient should receive 300mg of aspirin, followed by dual anti-platelet therapy for the first 21 days (clopidogrel 300mg loading dose followed by 75mg daily + aspirin 75-100mg daily) and monotherapy with aspirin 75-100mg daily for a total of 90 days.

  5. Perform evaluation of the cardiac rhythm with ECG and monitoring. Consider outpatient cardiac monitoring (3-week Holter monitor) or transesophageal echocardiography.

  6. The most important goal of TIA management is to prevent a recurrent, more severe ischemic event.

  7. The strongest predictors (in TIAregistry.org project study) of new vascular events were found to be carotid stenosis, atrial fibrillation, multiple ischemic spots on DWI, and an ABCD2 score of 6 or 7.

  8. Consider lifestyle modifications including lipid-lowering therapy, smoking cessation, blood pressure control, and diabetes control.

  9. ABCD2 score is no longer recommended for triage in certain guidelines (2019 NICE), as some studies have shown a score of <4 (previously considered lower risk) had a similar 3-month risk of stroke compared to the group with a score of >4.

Source
Transient Ischemic Attack. N Engl J Med. 2020 May 14;382(20):1933-1941. doi: 10.1056/NEJMcp1908837.

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