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/or 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 )
Carotid artery stenosis
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 Etiology of Anemia Anemia is a decrease in the number of red blood cells (RBCs), which leads to a decrease in hematocrit and hemoglobin content. (See also Red Blood Cell Production.) The RBC mass represents the... read more , carbon monoxide poisoning Carbon Monoxide Poisoning Carbon monoxide (CO) poisoning causes acute symptoms such as headache, nausea, weakness, angina, dyspnea, loss of consciousness, seizures, and coma. Neuropsychiatric symptoms may develop weeks... read more ), or increased blood viscosity (eg, severe polycythemia Polycythemia Vera Polycythemia vera is a chronic myeloproliferative neoplasm characterized by an increase in morphologically normal red cells (its hallmark), but also white cells and platelets. Ten to 15% of... read more ), 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 with a very high hematocrit due to chronic hypoxemia.
Symptoms and Signs of TIA
Neurologic deficits are similar to those of strokes (see table Selected Stroke Syndromes Selected Stroke Syndromes ). 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 Atrial Fibrillation Atrial fibrillation is a rapid, irregularly irregular atrial rhythm. Symptoms include palpitations and sometimes weakness, effort intolerance, dyspnea, and presyncope. Atrial thrombi may form... read more , 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.
Patients are at high risk of TIA if they have an ABCD2 score > 4.
The ABCD2 score is used to estimate risk of stroke after TIA and is calculated by adding the following:
A (age): ≥ 60 = 1
B (blood pressure): Systolic blood pressure ≥ 140 and/or diastolic blood pressure > 90 = 1
C (clinical features): Weakness = 2, speech disturbance without weakness = 1
D (TIA duration): ≥ 60 min = 2, 10 to 59 min = 1, < 10 minutes = 0
D2 (diabetes) = 1
Risk of stroke within 2 days based on the ABCD2 score is about
For a score of 6 to 7: 8%
For a score of 4 to 5: 4%
For a score of 0 to 3: 1%
All patients who have had a TIA require CT angiography, magnetic resonance angiography (MRA), or diffusion-weighted MRI of the carotid and cerebral circulation.
Treatment of TIA
Treatment of transient ischemic attacks is aimed at preventing strokes; antiplatelet medications 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 (> 70% ipsilateral carotid stenosis). 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 medications, statins, sometimes carotid endarterectomy or arterial angioplasty plus stenting).
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