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  • 1. Transient Ischemic AttacksTransient Ischemic Attacks Rodney W. Smith, MDRodney W. Smith, MD Clinical Assistant ProfessorClinical Assistant Professor Department of Emergency MedicineDepartment of Emergency Medicine University of MichiganUniversity of Michigan Ann Arbor, MIAnn Arbor, MI
  • 2. Rodney W. Smith, MD Example CaseExample Case • A 55 year old male presents to the emergency department with acute onset of – Left arm weakness: Unable to lift left arm off of lap – Symptoms improved on the way to the hospital
  • 3. Rodney W. Smith, MD Example CaseExample Case • PMHx: Hypertension – Takes enalapril • ROS: – No headache – No other neurologic symptoms • Social Hx: – Smokes 1 ppd
  • 4. Rodney W. Smith, MD Example CaseExample Case • Physical Exam – Overweight, in NAD – 160/90, 80, 14, 37.5C – Right carotid bruit – Heart with regular rate and rhythm; No murmur
  • 5. Rodney W. Smith, MD Example CaseExample Case • Neuro exam – Oriented to person, place, and time – Fluent speech – CN II-XII intact – Motor 4/5 strength in left upper extremity – Sensory subjective decrease in pinprick in left upper extremity compared to the right – DTR +2 except at left biceps +3 – Gait steady – Cerebellar intact finger to finger and finger to nose – No extensor plantar response.
  • 6. Rodney W. Smith, MD Summary • Importance of distinguishing TIA from other causes of transient “spells” • Essential elements include a careful history, physical exam, and CT scan • ED treatment and disposition are directed toward prevention of subsequent stroke • Incidence of early stroke after TIA justifies hospital admission for further evaluation
  • 7. Rodney W. Smith, MD Risk Factors/EpidemiologyRisk Factors/Epidemiology • 300,000 TIAs per year in US • 5-year stroke risk after TIA 29% – 43.5% in 2 years with >70% carotid stenosis treated medically • Many stroke patients have had TIA – 25% - 50% in large artery atherothrombotic strokes – 11% - 30% in cardioembolic strokes – 11% to 14% in lacunar strokes
  • 8. Rodney W. Smith, MD Risk Factors/EpidemiologyRisk Factors/Epidemiology • Risk factors are the same as stroke – Increasing age – Sex – Family history / Race – Prior stroke / TIA – Hypertension – Diabetes – Heart disease – Carotid artery / Peripheral artery disease – Obesity – High cholesterol – Physical inactivity
  • 9. Rodney W. Smith, MD ED PresentationED Presentation • What is a TIA? – Acute loss of focal cerebral function – Symptoms last less than 24 hours – Due to inadequate blood supply • Thrombosis • Embolism
  • 10. Rodney W. Smith, MD ED PresentationED Presentation • Acute loss of focal cerebral function – Motor symptoms • Weakness or clumsiness on one side • Difficulty swallowing – Speech disturbances • Understanding or expressing spoken language • Reading or writing • Slurred speech • Calculations
  • 11. Rodney W. Smith, MD ED PresentationED Presentation • Acute loss of focal cerebral function – Sensory symptoms • Altered feeling on one side • Loss of vision on one side • Loss of vision in left or right visual field • Bilateral blindness • Double vision • Vertigo
  • 12. Rodney W. Smith, MD ED PresentationED Presentation • Non-focal Symptoms (Not TIA) – Generalized weakness or numbness – Faintness or syncope – Incontinence – Isolated symptoms (symptoms occurring alone) • Vertigo or loss of balance • Slurred speech or difficulty swallowing • Double vision
  • 13. Rodney W. Smith, MD ED PresentationED Presentation • Non-focal Symptoms (Not TIA) – Confusion • Disorientation • Impaired attention/concentration • Diminution of all mental activity • Distinguish from – Isolated language or visual-spatial perception problems (may be TIA) – Isolated memory problems (transient global amnesia)
  • 14. Rodney W. Smith, MD TIA Symptoms RelatedTIA Symptoms Related to Cerebral Circulationto Cerebral Circulation Symptom Anterior Either Posterior Dysphasia Unilateral weakness Usually Unilateral sensory disturbance Usually Dysarthria Plus other Homonymous hemianopia Unsteadiness/ataxia Plus other Dysphagia Plus other Diplopia Plus other Vertigo Plus other Bilateral simultaneous visual loss Bilateral simultaneous weakness Bilateral simultaneous sensory disturbance Crossed sensory/motor loss Circulation Involved
  • 15. Rodney W. Smith, MD ED PresentationED Presentation • Acute loss of focal cerebral function – Abrupt onset – Symptoms occur in all affected areas at the same time – Symptoms resolve gradually – Symptoms are “negative”
  • 16. Rodney W. Smith, MD ED PresentationED Presentation • Symptoms last less than 24 hours – Most last less than one hour – Less than 10 percent > 6 hours – Amaurosis fugax up to five minutes
  • 17. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis • Migraine with aura – Positive symptoms – Spread over minutes – Visual disturbances – Somatosensory or motor disturbance – Headache within 1 hour
  • 18. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis • Aura without Headache – 98% Visual symptoms – 30% with other symptoms • 26% sensory • 16% aphasia • 6% dysarthria • 10% weakness – Mean age 48.7 (vs. 62.1) – Fewer cardiovascular risk factors
  • 19. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis Duration of symptoms 0% 20% 40% 60% 80% 15 15 to 60 > 60 Time in minutes Time to maximum symptoms 0% 10% 20% 30% 40% 50% < 1 1 to 5 6 to 30 >30 Time in minutes
  • 20. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis • Partial (focal) seizure – Positive sensory or motor symptoms – Spread quickly (60 seconds) – Negative symptoms afterward (Todd’s paresis) – Multiple attacks
  • 21. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis • Transient global amnesia – Sudden disorder of memory – Antegrade and often retrograde – Recurrence 3% per year – Etiology unclear • Migraine • Epilepsy (7% within 1 year) • Unknown
  • 22. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis • Transient global amnesia – No difference in vascular risk factors compared with general population – Fewer risk factors when compared with TIA patients – Prognosis significantly better than TIA
  • 23. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis • Structural intracranial lesion – Tumor • Partial seizures • Vascular steal • Hemorrhage • Vessel compression by tumor
  • 24. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis • Intracranial hemorrhage – ICH rare to confuse with TIA – Subdural hematoma • Headache • Fluctuation of symptoms • Mental status changes
  • 25. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis • Multiple sclerosis – Usually subacute but can be acute • Optic neuritis • Limb ataxia – Age and risk factors – Signs more pronounced than symptoms
  • 26. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis • Labyrinthine disorders – Central vs. Peripheral vertigo – Ménière's disease – Benign positional vertigo – Acute vestibular neuronitis
  • 27. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis • Metabolic – Hypoglycemia – Hyponatremia – Hypercalcemia • Peripheral nerve lesions – Entrapments – Painful quality
  • 28. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis O x f o r d s h ir e C o m m u n it y S t r o k e P r o j e c t 5 2 ( 1 0 % ) M i g r a i n e 3 3 ( 6 % ) V e r t i g o 4 8 ( 9 % ) S y n c o p e 2 9 ( 6 % ) E p i l e p s y 4 6 ( 9 % ) P o s s . T IA 1 7 ( 3 % ) T G A 4 5 ( 9 % ) F u n n y t u r n 4 7 ( 9 % ) O t h e r 3 1 7 O t h e r s 1 9 5 ( 3 8 % ) w i t h T IA 5 1 2 P a t i e n t s r e f e r r e d f o r s u s p e c t e d T IA
  • 29. Rodney W. Smith, MD ED PresentationED Presentation Differential DiagnosisDifferential Diagnosis • Patient evaluation by senior neurologists with interest in stroke • Agreement on 48 of 56 patients (85.7%) – 36 with TIA – 12 Not TIA – 8 of 56 disagreement • 4 of these, both listed firm diagnosis
  • 30. Rodney W. Smith, MD ED Diagnosis and EvaluationED Diagnosis and Evaluation • History – Characteristics of the attack – Associated symptoms – Risk factors • Vascular Disease • Cardiac Disease • Hematologic Disorders • Smoking – Prior TIA
  • 31. Rodney W. Smith, MD ED Diagnosis and EvaluationED Diagnosis and Evaluation • Physical Examination – Neurologic Exam – Carotid Bruits – Cardiac Exam – Peripheral Pulses
  • 32. Rodney W. Smith, MD ED Diagnosis and EvaluationED Diagnosis and Evaluation • EKG • CBC, Coags, and Chemistries • Chest Xray • Head CT without contrast • Expedite if early presentation
  • 33. Rodney W. Smith, MD ED Diagnosis and EvaluationED Diagnosis and Evaluation • Symptom vs. Disease – Significant carotid artery stenosis – Cardiac embolism • Admission vs. Discharge – Traditional approach – Trend toward outpatient evaluation
  • 34. Rodney W. Smith, MD ED Diagnosis and EvaluationED Diagnosis and Evaluation • Stroke Rate After TIA – Percent (95% CI) Oxfordshire Rochester 1 month 4.4 (1.5 - 7.3) 8 (4.2 - 11.8) 6 months 8.8 (4.7 - 12.9) 10 (6.7 - 14.3) 12 months 11.6 (6.9 - 16.3) 13 (8.1 - 17.9) 5 years 29.3 (21.3 - 37.3) 29 (22.0 - 36.0)
  • 35. Rodney W. Smith, MD ED Diagnosis and EvaluationED Diagnosis and Evaluation • Stroke Rate After TIA • Johnston, et al. JAMA 284:2901, 2000. – Follow-up of 1707 ED patients diagnosed with TIA – Stroke rate at 90 days was 10.5% – Half of these occurred in the first 48 hours after ED presentation
  • 36. Rodney W. Smith, MD ManagementManagement • Goal: Prevention of Stroke • Expedited Evaluation – Carotid Artery Disease – Cardioembolism – Inpatient vs. Observation Unit vs. Outpatient • Antiplatelet Therapy • Risk Factor Modulation
  • 37. Rodney W. Smith, MD ManagementManagement ED DispositionED Disposition • Discharge – Further testing will not change treatment – Prior workup – Not a candidate for CEA or anticoagulation
  • 38. Rodney W. Smith, MD ManagementManagement ED DispositionED Disposition • Admission – Clear indication for anticoagulation – Severe deficit – Crescendo symptoms – Other indication for admission • Admission or observation unit evaluation – All others
  • 39. Rodney W. Smith, MD ManagementManagement Diagnosis of Carotid StenosisDiagnosis of Carotid Stenosis Carotid bruit related to stenosis 0% 10% 20% 30% 40% Normal 1 - 24 25 - 49 50 - 74 75 - 99 Occluded Percent stenosis of symptomatic ICA Percentofpatients No Bruit Bruit
  • 40. Rodney W. Smith, MD ManagementManagement Diagnosis of Carotid StenosisDiagnosis of Carotid Stenosis • Carotid Duplex Ultrasound – Sensitivity of 94 - 100% for > 50% stenosis – May overdiagnose occlusion – Non-invasive
  • 41. Rodney W. Smith, MD ManagementManagement Diagnosis of Carotid StenosisDiagnosis of Carotid Stenosis • Magnetic Resonance Angiography – Similar sensitivity to carotid ultrasound – Overestimates degree of stenosis – Gives information about vertebrobasilar system – Accuracy of 62% in detecting intracranial pathology – Cost and claustrophobia
  • 42. Rodney W. Smith, MD ManagementManagement Diagnosis of Carotid StenosisDiagnosis of Carotid Stenosis • Cerebral Angiography – Gold standard for diagnosis – Invasive, with risk of stroke of up to 1% – For patients with positive ultrasound – For patients with occlusion on ultrasound – First test if intracranial pathology suspected
  • 43. Rodney W. Smith, MD ManagementManagement Cardiogenic EmbolismCardiogenic Embolism • Major risk factors: Anticoagulation Indicated – Atrial fibrillation – Mitral stenosis – Prosthetic cardiac valve – Recent MI – Thrombus in LV or LA appendage – Atrial myxoma – Infective endocarditis (No anticoagulation) – Dilated cardiomyopathy
  • 44. Rodney W. Smith, MD ManagementManagement Cardiogenic EmbolismCardiogenic Embolism • Minor risk factors: Best treatment unclear – Mitral valve prolapse – Mitral annular calcification – Patent foramen ovale – Atrial septal aneurysm – Calcific aortic stenosis – LV regional wall motion abnormality – Aortic arch atheromatous plaques – Spontaneous echocardiographic contrast
  • 45. Rodney W. Smith, MD ManagementManagement EchocardiogramEchocardiogram • Yield < 3% in undifferentiated patients • Higher with risk factors • TEE preferred • Specific treatment of many abnormalities unknown
  • 46. Rodney W. Smith, MD ManagementManagement EchocardiogramEchocardiogram • Indications – Age < 50 – Multiple TIAs in more than one arterial distribution – Clinical, ECG, or CXR evidence suggests cardiac embolization
  • 47. Rodney W. Smith, MD ManagementManagement TIA with Atrial FibrillationTIA with Atrial Fibrillation • INR 2.5 (Range 2 to 3) • Aspirin if Warfarin contraindicated • Timing of onset of AC not proven in RCT • AC in other causes of cardioembolic stroke not proven in RCT EAFT Study Group, Lancet, 1993
  • 48. Rodney W. Smith, MD ManagementManagement Antiplatelet TherapyAntiplatelet Therapy • Aspirin – Compared with placebo in patients with minor stroke/TIA • Relative risk of composite endpoint reduced by 13% to 17% – Dose of aspirin probably not important – Lower dose gives lower incidence of GI side effects.
  • 49. Rodney W. Smith, MD ManagementManagement • Ticlopidine – Small absolute risk reduction compared with ASA – Side effects preclude use in up to 5% – Serious adverse effects • Neurtropenia • Thrombotic thrombocytopenic purpura
  • 50. Rodney W. Smith, MD ManagementManagement • Clopidogrel – Similar to Ticlopidine in reducing composite endpoint – Reduction in risk of stroke alone less than with Ticlopidine – Similar side effect profile to ASA
  • 51. Rodney W. Smith, MD ManagementManagement • Dipyridamole plus ASA – Small absolute risk reduction for stroke compared with ASA alone – Risk reduction for composite endpoint due to stroke reduction alone – Safe side effect profile
  • 52. Rodney W. Smith, MD ManagementManagement • Discharged patients should receive ASA 50 - 325 mg/day – Based on cost and small absolute benefit of other agents • Patients with TIA on ASA should have change in agent – Dipyridamole plus ASA – Clopidogrel – Increase dose of ASA to 1300 mg/day
  • 53. Rodney W. Smith, MD Expected OutcomeExpected Outcome • 70% stenosis or greater • Best medical therapy vs. CEA Medical Surgical Ipsilateral stroke 26.0% 9.0% Major or fatal ipsilateral stroke 13.1% 2.5% Stroke or death 32.3% 15.8%
  • 54. Rodney W. Smith, MD Expected OutcomeExpected Outcome • 50 - 69% stenosis • Best medical therapy vs. CEA Medical Surgical Ipsilateral stroke 22.2% 15.7% Stroke or death 43.3% 33.2%
  • 55. Rodney W. Smith, MD Expected OutcomeExpected Outcome TIA with Atrial FibrillationTIA with Atrial Fibrillation • Rate of stroke – Placebo - 12% per year – Aspirin - 10% per year – Warfarin - 4% per year • Major bleed in 2.8% per year • No increase in ICH occurrence EAFT Study Group, Lancet, 1993
  • 56. Rodney W. Smith, MD Future directionsFuture directions • Treatment of PFO in patients with TIA – ASA; Warfarin; Surgery • Ongoing trials of Warfarin vs. ASA for secondary stroke prevention • Ongoing trials of carotid artery angioplasty and stents
  • 57. Rodney W. Smith, MD Outcome of CaseOutcome of Case • Patient was evaluated in an Observation Center – Carotid ultrasound demonstrated 80% stenosis of R ICA – Underwent R CEA, without complication – Patient discharged with plan for risk modification • Diet for weight reduction • Smoking cessation program • Optimized antihypertensive regimen
  • 58. Rodney W. Smith, MD SummarySummary • Importance of distinguishing TIA from other causes of transient “spells” • Essential elements include a careful history, physical exam, and CT scan • ED treatment and dispostition are directed toward prevention of subsequent stroke • Incidence of early stroke after TIA justifies hospital admission for further evaluation