Transient Ischemic Attack: Review for the Emergency Physician

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Transient Ischemic Attack Review for the
Emergency Physician

• Annals of emergency medicine 435 593-604, May
  2004

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Introduction

• Stroke the leading cause of disability and third
  leading cause of death
• Aggressive intervention for TIA to prevent stroke
  just as treat angina to prevent AMI
• 1/15 people gt 65 years-old had history of TIA
  (JAMA 2002)

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Introduction

• Untreated TIA became stroke
• 4 8 in 1 months and 24 29 in 5 years (
  Heart Dis Stroke 1994)
• 10.5 in 90 days and half of them occurred in
  first 48 hours ( JAMA 2002 )
• Fist time TIA ( Stroke 2003 )
• 8.6 became stroke in first 7 days
• 12 became stroke in 30 days
• 31 of patient with TIA not have further
  evaluation in further 1 month ( Arch Intern Med
  2000 )

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Introduction

• How is a TIA defined ?
• Does the patient have a TIA ?
• Once TIA is diagnosed, what diagnostic testing
  should be done ( and when )?
• What treatment should be instituted ( and when) ?
• What is the correct disposition?
• What are the current medical guidelines?

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How is a TIA defined?

• Classic definition
• A neurologic deficit caused by focal brain
  ischemia that complete resolves within 24 hours
  1970s
• New definition
• A brief episode of neurologic dysfunction cause
  by focal brain or retinal ischemia, with clinical
  symptoms typically lasting less than 1 hour and
  without evidence of acute infarction -- NEJM
  2002

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How is a TIA defined?

• MRI findings
• Infarction was found in 2/3 of the patient with
  clinical TIA diagnosis.
• Tissue-based rather than time-based
• Transient neurologic symptoms from temporary
  ischemia or stroke?????

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Does the patient have a TIA ?

• Etiology Atherothromboembolism, cardiogenic
  embolism, and small vessel disease account for
  95 of TIA
• Historical clues

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Does the patient have a TIA ?
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Does the patient have a TIA ?-- Different
diagnosis

• Multiple Sclerosis by history
• Complicated migraines previous aura
• Isolated Vertigo ?? 25 elderly patient have
  caudal cerebellar infarction ( Acta Neurol Scand.
  1995 )
• Menieres disease Acoustic schwannomas
  tinnitus and hearing loss

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-- Different diagnosis
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What diagnostic testing should be done ( and when
)?

• Neurologic examination, ECG and brain imaging
• NE focal neurologic deficit gt 1 hour or rapidly
  improved in 3 hours 98 had cerebral infarction
• ECG Caridogenic emboli and Af
• 2 TIA due to new-onset Af ( Arch Neurology 2002 )

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What diagnostic testing should be done ( and when
)?

• CT
• Infarction or Hemorrhage
• 1 of TIA patient had nonischemic findings.
• MRI
• Disadvantage Less reliable for detect recent
  bleeding, Slower, Expensive, Logistic difficulty
• DWI the ideal test, can detect ischemia within
  minutes.

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What diagnostic testing should be done ( and when
)?

• Vascular territory
• Can be done in the outpatient
• Ultrasonography Carotid / Transcranial Doppler
• MRA v.s CTA
• TTE v.s TEE

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What diagnostic testing should be done ( and when
)?
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What diagnostic testing should be done ( and when
)?
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What treatment should be instituted ( and when) ?

• Maintain perfusion to the brain and avoid lower
  blood pressure
• Fluid resuscitation
• Antiplatelet
• Aspirin low dose or high dose ??
• Aspirin dipyridamole (Persantin)
• EPSP study 37 reduce stroke
• Ticlopidine (Ticlid) 2.4 neutropenia
• Clopidogrel (Plavix)

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What treatment should be instituted ( and when) ?

• Antiplatelet

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What treatment should be instituted ( and when) ?

• Anticoagulation
• Warfarin benefit in TIA due to Cardiogenic
  emboli
• Carotid endaterectomy
• Benefit in high grade stenosis
• Angioplasty and stenting
• Risk Factor modification
• HTN, DM, smoking, hypercholesterolemia, excessive
  alcohol drinking, sedentary lifestyle

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What is the correct disposition?

• No clear guideline to demonstrated a benefit of
  hospital admission or significant detriment with
  discharge to home

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What are the current medical Guidelines?
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Much Thanks ??????????!!c