ISCHEMIC STROKE

Transient ischemic attack (TIA)

Created 23/03/2021, last revision 16/09/2022

2021 ESO guidelines on the management of transient ischemic attack (TIA)

  • a transient ischemic attack (TIA) is a medical emergency
  • despite its seemingly mild course, TIA is a serious predictor of subsequent ischemic stroke and death
    • following TIA, the risk of recurrent stroke is 8% in the first week, 11.5% at 1 month, and 17.3% at 3 months    [Coull, 2004]
  • true incidence and prevalence of TIA are challenging to determine because of inconsistent criteria
    • the reported crude annual incidence rate for the TIA was 35.2 per 100 000 (95% CI, 30.6–40.3) and 28.6/100 000 (95% CI, 24.1–33.5) when standardized to the 2011 European population. TIAs are rare in young adults (<45 years) and relatively rare in subjects aged 45–64 years; after that, the incidence steeply increased, peaking in subjects aged ≥ 85 years, in all sexes  [Degan, 2017]
  • evaluation of TIA and initiation of multimodal therapeutic interventions should be urgent to decrease the risk of subsequent stroke
    • especially TIAs within 24-48 h should be managed as a stroke
Recurrent stroke risk after transient ischemic attack (TIA) and minor stroke (Coull, 2004)

TIA definition

  • the former definition of TIA (sudden focal neurological deficit lasting < 24h with presumed vascular origin) became obsolete
    • about 30-50% of such defined TIA patients have infarct lesions on DWI   [Oppenheim, 2004]
    • the likelihood of a DWI lesion increases with symptom duration; DWI is positive in over 60% of TIA cases lasting > 30 min  [Inatomi, 2004]
New TIA definition [Albers, 2002]
Transient episode of neurologic dysfunction due to the focal brain, spinal cord, or retinal ischemia, usually lasting < 1h, without acute infarction or tissue injury.

TIA or stroke?

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Etiology

  • TIA subtypes, classified according to the pathophysiological mechanisms, are similar to ischemic stroke subtypes  → TOAST classification of stroke
  • the common vascular risk factors are the same as in stroke (e.g., diabetes, hypertension, age, smoking, unhealthy diet and obesity, alcoholism, stress, and lack of physical activity)

Clinical presentation

  • TIA symptoms are sudden in onset
  • TIAs usually last a few minutes with complete resolution of symptoms and signs
  • the signs and symptoms of a TIA resemble those found in a stroke:
    • hemiparesis, quadruparesis
    • hemihypesthesia
    • speech disturbances
      • aphasia
      • slurred speech (dysarthria)
    • vision disturbances
      • blindness in one or both eyes, visual field deficit
      • double vision
    • vestibular syndrome
    • cerebellar syndrome (ataxia, dysmetria)
  • global symptoms (lightheadedness, isolated delirium, syncope) and positive symptoms (scintillations) are not typical for a TIA

Diagnostic evaluation

  • TIA very often occurs hours or days before a stroke; it can thus serve as both a warning of a future stroke and an opportunity to prevent it
  • prompt evaluation and identification of potentially treatable conditions are essential
    • specialist review  of a patient within 24 h after the onset of symptoms is recommended (ESO guidelines 2021)
    • review in a TIA clinic or hospitalization in a stroke unit are reasonable options (depending on local available resources and the patient´s preferences)
  • the main goals of a TIA evaluation:
    • to prove the vascular origin of the symptoms and to exclude an alternative nonischemic origin
      • because of the often already negative neurological finding, the history of symptoms must be carefully discussed (can help diagnose TIA or even its etiology)
      • uniform repeated attacks indicate either pathology at the level of some peripheral branch or stroke mimic (migraine etc.)  ⇒ differentiating TIA from the “stroke mimics“
    • to determine the underlying vascular mechanism to select the optimal therapy
      • it is most important to exclude significant carotid stenosis and major cardioembolic source
      • palpitations, arrhythmias, and valve defects together with symptoms and signs from various territories, point toward a cardiac etiology (TOAST 2)

Who should be admitted to hospital?

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ABCD2 score

  • transient ischemic attack (TIA) is a medical emergency defined as a brief episode of neurologic dysfunction due to focal brain, spinal cord, or retinal ischemia, without acute infarction or tissue injury (negative imaging)
  • TIA requires swift evaluation and therapy to decrease the risk of subsequent stroke (about 1 in 3 people with TIA will eventually have a stroke)
  • the ABCD2 score is a simple clinical prediction tool helping to stratify patients presenting with a TIA according to their stroke risk
  • ≥ 4 points ⇒ high risk of stroke; hospitalization is recommended (2-day stroke risk is > 4%, 7-day stroke risk: 5.9%!)
  • always use this score together with clinical judgment and brain and vessel imaging findings!
ABCD2 score
(max. 7 points, high stroke risk ≥ 4 )
A Age ≥ 60 years
1
B  BP ≥ 140/90 mmHg (either SBP ≥ 140 or DBP ≥ 90)
1
C Clinical features of the TIA
Unilateral weakness
Speech disturbance without weakness
2
1
D Duration of symptoms
<10 minutes
10-59 minutes
≥ 60 minutes
0
1
2
D History of diabetes
1
0-3
low risk
2-Day Stroke Risk: 1.0%
7-Day Stroke Risk: 1.2%
90-Day Stroke Risk: 3.1%
 outpatient management
4-5
medium risk
2-Day Stroke Risk: 4.1%
7-Day Stroke Risk: 5.9%
90-Day Stroke Risk: 9.8%
 hospitalization rather recommended
6-7
high risk
2-Day Stroke Risk: 8.1%
7-Day Stroke Risk: 11.7%
90-Day Stroke Risk: 17.8%
 hospitalization recommended
Stroke risk according to ABCD2 score

[Johnston, Lancet 2007]

Acute evaluation of TIA patient

  • focused history
    • onset, duration, timing,  symptoms specification, any aggravating or relieving factors
    • risk factors, concomitant diseases (CAD or PAD,  smoking, drug abuse, obesity, diabetes mellitus, dyslipidemia, and hypertension)
  • clinical exam
    • assess neurological deficits, including speech disturbances, visual field defects, etc.
    • cardiac examination
    • carotid auscultation for a carotid bruit detection
  • brain imaging (preferred modality is DWI within 24h or CT+CTP  if DWI cannot be performed) (ESO 2021)  (AHA/ASA 2013 I/B)
    • DWI has a greater sensitivity than CT for detecting small infarcts
  • vessel examination – neurosonology  or  CTA/MRA (urgent in recent TIA) ( AHA/ASA guidelines 2013 I/A)
    • ESO guidelines 2021 suggest using MRA or CTA for confirmation of large artery stenosis ≥ 50% detected by ultrasound, in order to guide further management
    • strength of MRA compared to ultrasound and CTA is its relative insensitivity to arterial calcifications
  • blood tests
    • complete blood count (CBC) + coagulation + ESR
    • biochemistry panel
    • lipid panel
    • diabetes mellitus screening
    • urine drug screen in selected cases
  • ECG
    • standard ECG  (AFib?)
    • continue with Holter ECG or prolonged ECG monitoring for at least three weeks (with loop recorder)
    • prolonged cardiac rhythm monitoring is reasonable, especially in patients with cortical infarcts with no clear source to exclude paroxysmal AFib
  • TTE (transthoracic echocardiogram) + TEE (transesophageal echocardiogram)
    • search for PFO,  valve, and other intracardial abnormities, aortic plaques
  • EEG in DDx of stroke mimics

→ etiological diagnosis and classification of stroke see here

Differencial diagnosis

  • differentiate TIA from stroke mimics

Therapy and prevention

  • immediately start multimodal therapeutic intervention
  • treatment may substantially reduce the risk of a future stroke or recurrent TIA (by 80%) – EXPRESS trial 
    • the same-day assessment and initiation of standard risk-modification measures following TIA decreased the 90-day risk of stroke from 10.3 to 2.1% compared with delayed (or routine) out-patient evaluation and treatment
    • early treatment did not increase the risk of intracerebral haemorrhage or other bleeding.

Antithrombotic therapy

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Surgery and endovascular procedures

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Vascular risk factors management and others

  • start aggressive blood pressure treatment (⇒ BP < 135/85 mm Hg, ACE-I are preferred)   → acute blood pressure management
  • treat hyperlipidemia
  • manage other vascular risk factors
  • consider specific treatment of some particular underlying etiologies (vasculitis, etc.)
  • even in TIA patients, post-traumatic stress disorder (PTSD) with depression or anxiety may develop  (Kiphuth, 2014]
    • train adaptive coping strategies and cautiously brief about the realistic stroke risk associated with TIA
    • if needed, use anxiolytics or antidepressants
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