TIA is similar to ischemic stroke Ischemic Stroke Ischemic stroke is sudden neurologic deficits that result from focal cerebral ischemia associated with permanent brain infarction (eg, positive results on diffusion-weighted MRI). Common causes... read more except that symptoms usually last < 1 hour; most TIAs last < 5 minutes. Infarction is very unlikely if deficits resolve within 1 hour. As shown by diffusion-weighted MRI and other studies, deficits that resolve spontaneously within 1 to 24 hours are often accompanied by infarction and are thus no longer considered TIAs.
TIAs are most common among middle-aged and older people. TIAs markedly increase risk of stroke, beginning in the first 24 hours.
Etiology of TIA
Risk factors for TIA are the same as those for ischemic stroke. Modifiable risk factors include the following:
Excess alcohol consumption
Lack of physical activity
High-risk diet (eg, high in saturated fats, trans fats, and calories)
Heart disorders (particularly disorders that predispose to emboli, such as acute myocardial infarction Acute Myocardial Infarction (MI) Acute myocardial infarction is myocardial necrosis resulting from acute obstruction of a coronary artery. Symptoms include chest discomfort with or without dyspnea, nausea, and diaphoresis.... read more , infective endocarditis Infective Endocarditis Infective endocarditis is infection of the endocardium, usually with bacteria (commonly, streptococci or staphylococci) or fungi. It may cause fever, heart murmurs, petechiae, anemia, embolic... read more , and atrial fibrillation Atrial Fibrillation and Wolff-Parkinson-White Syndrome (WPW) In Wolff-Parkinson-White syndrome, antegrade conduction occurs over an accessory pathway. If atrial fibrillation, develops this is a medical emergency as very rapid ventricular rates can develop... read more )
Use of certain drugs (eg, cocaine, amphetamines)
Unmodifiable risk factors include the following:
Family history of stroke
Most TIAs are caused by emboli, usually from carotid or vertebral arteries, although most of the causes of ischemic stroke Etiology Ischemic stroke is sudden neurologic deficits that result from focal cerebral ischemia associated with permanent brain infarction (eg, positive results on diffusion-weighted MRI). Common causes... read more can also result in TIAs.
Uncommonly, TIAs result from impaired perfusion due to severe hypoxemia, reduced oxygen-carrying capacity of blood (eg, profound anemia, carbon monoxide poisoning), or increased blood viscosity (eg, severe polycythemia), particularly in brain arteries with preexisting stenosis. Systemic hypotension does not usually cause cerebral ischemia unless it is severe or arterial stenosis preexists because autoregulation maintains brain blood flow at near-normal levels over a wide range of systemic blood pressures.
In subclavian steal syndrome, a subclavian artery stenosed proximal to the origin of the vertebral artery “steals” blood from the vertebral artery (in which blood flow reverses) to supply the arm during exertion, causing signs of vertebrobasilar ischemia.
Occasionally, TIAs occur in children with a severe cardiovascular disorder that produces emboli or a very high hematocrit.
Symptoms and Signs of TIA
Neurologic deficits are similar to those of strokes (see table Selected Stroke Syndromes Selected Stroke Syndromes A transient ischemic attack (TIA) is focal brain ischemia that causes sudden, transient neurologic deficits and is not accompanied by permanent brain infarction (eg, negative results on diffusion-weighted... read more ). Transient monocular blindness (amaurosis fugax), which usually lasts < 5 minutes, may occur when the ophthalmic artery is affected.
Symptoms of TIAs begin suddenly, usually last 2 to 30 minutes, then resolve completely. Patients may have several TIAs daily or only 2 or 3 over several years. Symptoms are usually similar in successive carotid attacks but vary somewhat in successive vertebrobasilar attacks.
Diagnosis of TIA
Resolution of stroke-like symptoms within 1 hour
Evaluation to identify the cause
Transient ischemic attacks are diagnosed retrospectively when sudden neurologic deficits referable to ischemia in an arterial territory resolve within 1 hour.
Isolated peripheral facial nerve palsy, loss of consciousness, or impaired consciousness does not suggest TIA. TIAs must be distinguished from other causes of similar symptoms, such as
Postictal [Todd] paralysis (a transient neurologic deficit, usually weakness, of the limb contralateral to the seizure focus)
Because an infarct, a small hemorrhage, and even a mass lesion cannot be excluded clinically, neuroimaging is required. Usually, CT is the study most likely to be immediately available. However, CT may not identify infarcts for > 24 hours. MRI usually detects evolving infarction within hours. Diffusion-weighted MRI is the most accurate imaging test to rule out an infarct in patients with presumed TIA but is not always available.
The cause of a TIA is sought as for causes of ischemic strokes Etiology Ischemic stroke is sudden neurologic deficits that result from focal cerebral ischemia associated with permanent brain infarction (eg, positive results on diffusion-weighted MRI). Common causes... read more ; evaluation includes tests for carotid stenosis, cardiac sources of emboli, atrial fibrillation, and hematologic abnormalities and screening for stroke risk factors. Because risk of subsequent ischemic stroke is high and immediate, evaluation proceeds rapidly, usually on an inpatient basis. It is not clear which patients, if any, can be safely discharged from the emergency department. Risk of stroke after TIA or minor stroke is highest within the first 24 to 48 hours, so if either is suspected, patients are typically admitted to the hospital for telemetry and evaluation.
Treatment of TIA
Treatment of transient ischemic attacks is aimed at preventing strokes; antiplatelet drugs and statins are used. Carotid endarterectomy or arterial angioplasty plus stenting can be useful for some patients, particularly those who have no neurologic deficits but who are at high risk of stroke. Anticoagulation is indicated if cardiac sources of emboli are present.
Modifying stroke risk factors, when possible, may prevent stroke.
A focal neurologic deficit that resolves within 1 hour is almost always a transient ischemic attack.
Test as for ischemic stroke.
Use the same treatments used for secondary prevention of ischemic stroke (eg, antiplatelet drugs, statins, sometimes carotid endarterectomy or arterial angioplasty plus stenting).