2. • Definitation: “episodes of temporary and focal
dysfunction of vascular origin, which are
variable in duration, commonly lasting from 2
to 15 minutes, but occasionally lasting as long
as a 24 hours; they leave no persistent
neurologic deficit” Advisory Council for the National Institute of
Neurological and Communicative Disorders and Stroke. A classification and outline of
cerebrovascular diseases,II. Stroke 1975;6:564–616
3. • It is estimated that 30% of the events that were
previously diagnosed as TIA actually have
infarcted brain.
Sacco RL, Kasner SE, Broderick JP, et al, American Heart Association Stroke
Council, Council on Cardiovascular Surgery and Anesthesia. An updated
definition of stroke for the 21st century: a statement for healthcare
professionals from the American Heart Association/American Stroke
Association. Stroke 2013;44:2064–89.
• New definition of TIA has evolved into a tissue-
based definition: “transient episode of neurologic
dysfunction caused by focal brain, spinal cord, or
retinal ischemia, without acute infarction.”
4. Stat CT Brain?
• CT is not nearly as sensitive as MRI and may
require 12 hours after the event to
demonstrate injury.
• MRI more sensitive and more specific for
acute injury and turns positive much sooner.
• Although most TIAs last less than 1 hour, up to
50% of patients with TIA lasting 1 to 24 hours
have negative MRI, confirming the absence of
stroke.
5. TIA- tissue base defination
Nondisabling stroke
• transitory presence of
neurologic symptoms with
mild (National Institutes of
Health Stroke Scale 3) to
absence of persistent
clinical deficits in the
presence of imaging
evidence of necrosis.
Silent stroke
• is the radiologic finding of
cerebral necrosis without
neurologic findings.
6. Risk of developing stroke
• Early outcome studies on the risk of stroke
after TIA estimated an incidence of 3% to 10%
at 2 days and 9% to 17% at 90 days.
Mozaffarian D, Benjamin EJ, Go AS, et al, American Heart
Association Statistics Committee and Stroke Statistics
Subcommittee. Heart disease and stroke statistics– 2015 update:
a report from the American Heart Association. Circulation
2015;131(4):e29–322
8. Look hard for etiology!!
• Cardioembolism has been associated with
severely debilitating strokes, and is an
independent predictor of mortality.
• Atrial fibrillation is the most common cause,
has a highly variable average annual risk of
first-time stroke in patients who are not
anticoagulated.
9.
10. High priority to rule out
• hypoglycemia,
• Stroke
• central nervous system (CNS) mass lesions
• CNS vasculitis
• CNS infections
• hypokalemia (Although rare, has been
reported in case reports to present with focal
deficits)
11. History
Negative symptoms
A loss of a function:
• such as motor (weakness),
• speech (decreased or
altered speech)
• visual (diminished vision)
• sensation (anesthesia)
(suggest ischemia or
infarction)
Positive symptoms
Presence of something that is not
normal:
• such as motor (involuntary
motions)
• speech (increased volume of
incomprehensible speech)
• visual (flashes of light or
scintillating scotoma)
• sensation (dysesthesias), and
sometimes pain
(suggest migraine or seizure-
related diagnoses)
12. History
“if the symptoms have not resolved, TIA cannot
be diagnosed and the patient should be
assumed to have a stroke, or a stroke mimic”
• “dizziness,” which, at least in the case of
vertigo, is a positive symptom and can be due
to posterior circulation ischemia; in particular,
even without any other neurologic sign, it has
been associated with TIA or stroke in 0.7% of
dizzy patients”
13. • Most TIAs are brief, most lasting less than 1
hour; in up to 50% of patients with symptoms
lasting more than 1 hour, radiologic evidence
of infarction can be found.
• Physical examination: Normal in full CNS
examination
• Lab investigation : FBC -> thrombocytosis
14. Cardiac assessment
• An electrocardiogram (ECG) is recommended to
assess for a cardioembolic mechanism, including
atrial fibrillation, ventricular hypertrophy, or signs
of cardiac ischemia (Class of evidence IB).
• Transthoracic echocardiography (TTE) is used to
assess for evidence of cardiac hypertrophy,
ventricular hypokinesis or thrombus, mitral
stenosis, and valve disease (Class of evidence
IIaA).
15. Brain Imaging
• The 2013 ASA guidelines state that patients with
transient ischemic neurologic symptoms should
undergo neuroimaging evaluation within 24
hours of symptom onset or as soon as possible in
patients with delayed presentations.
• The sensitivity of CT scan in identifying stroke
within 12 hours of symptom onset is only 0.39.
• MRI>>>CT Brain
16. A 78-year-old man with episode of dysarthria lasting 20 minutes. Head CT scan (on
the left) done after 3 hours from episode showing no acute alteration. DWI MRI (on
the right) done right after the CT revealing punctate area of restricted diffusion in
the right insula (arrow) compatible with infarction
18. Limitation of ABCD2 Score
• up to 41% of the patients with a high score (>4) have
been found to have TIA mimics,
• up to 21% of patients with low score have a high-risk
etiology, such as atrial fibrillation or carotid stenosis.
• measurements favor identifying anterior circulation
strokes and miss posterior circulation findings, such as
dizziness or sensory loss.
“ABCD2 score does provide a framework for
approaching clinical decision making in these patients.”
NEW: ABCD2-I score has been proposed in which
neuroimaging is added to the formula
19. Which Score To Use?
“The perfect scoring system has yet to be
developed, and clinical acumen based on a
careful history and physical must be
incorporated into the clinical decision making”
Kiyohara T, Kamouchi M, Kumai Y, et al. ABCD3 and ABCD3-I scores are superior to
ABCD2 score in the prediction of short- and long-term risks of stroke after transient ischemic
attack. Stroke 2014;45(2):418–25
20. Treatment
• The goal in TIA treatment
is to prevent subsequent
stroke.
• There are 3 main
therapeutic actions that
reduce stroke occurrence:
antiplatelet therapy
anticoagulant therapy
surgical or endovascular
treatment of significant
arterial stenosis
• Underlying disease eg
HPT, DM,
hypercholesrolemia.
21. Immediate Rx
• One trial it has been shown that the supine
position ensures an increased cerebral flow
compared with the seating or standing position.
• Oxygen administration is recommended only in
case of hypoxia (ie oxygen saturation <94% on
room air) and should be avoided in nonhypoxic
patients(Class of evidence IIIB).
Guidelines for the early management of patients with acute ischemic
stroke: a guideline for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke 2013;44:870–
947
22. Anticoagulant
• In cases of nonvalvular atrial fibrillation, the
2013 ASA stroke guidelines recommend
starting an anticoagulant within 14 days of the
event.
23. Antiplatelet
• Antiplatelet therapy is recommended in all cases of
noncardioembolic TIA (Level of evidence IA).
• There are 5 conditions when double antiplatelet therapy
with aspirin and clopidogrel should be considered:
high-risk TIA (large artery atherosclerosis and
cardioembolic disease) within the first 24 hours,
TIA associated with severe (70%–99%) intracranial arterial
stenosis within the first 3 days
TIA with intracranial or carotid symptomatic stenosis with
microembolic signs within 7 days
extracranial vertebral stenting with bare metal stents,
TIA with aortic arch atherosclerotic plaque or mobile
thrombosis or patches.
24. Disposition
• 2009 AHA guidelines used the ABCD2 score
recommending that hospitalization:
ABCD2 score greater than 2
evidence of focal ischemia
or for any patient in whom rapid follow-up as
an outpatient cannot realistically be obtained
within 2 days
