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Professor Eyad Qunaibi Page/Channel

Course:

Topics in General Neurology (101)

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Week1: Transient Ischemic Attack

(TIA)

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Fawzi Abukhalil, MD

-Neurologist

-Neuro-Ophthalmologist

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March 15, 2022

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Learning Objectives

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  • Definition of TIA?
  • Evaluation of the Risk of Stroke After TIA?
  • ABCD2 Scoring System
  • When to Admit Patients to the Hospital with TIA?
  • Work up of TIA?
  • Management of TIA?

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CASE

A 60 years old male with Past Medical history of Hypertension and Diabetes, present to Emergency Room with Sudden onset of aphasia, right upper extremity weakness, and right Lower extremity aphasia. BP on ED arrival was 190/100. Exam: Left Gaze deviation, Expressive Aphasia, Right lower facial weakness, and No movement in his right upper extremity and right lower extremity.

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What is your Next Step?

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  • CT Brain without contrast

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CT Brain was done

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  • No Evidence of acute Intracranial bleeding
  • Possible Left Middle Cerebral Artery Stroke

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CTA Head and MRI brain

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  • Left Middle Cerebral artery occlusion
  • MRI: Acute Left Middle Cerebral Artery Stroke

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Further History

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  • Patient Reported History of same side weakness 3 days ago, that resolved after 15 minutes, and he didn’t go to the hospital since symptoms resolved.
  • Prior TIA!!!!

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Definition of TIA

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  • Rapid onset
  • Brief episode of neurological dysfunction caused by focal Ischemia without evidence of acute infarction
  • Unilateral
  • Clinical symptoms: minutes to hour, ( < 24 hours)
  • Annual Incidence in USA: 200,000 to 500,000 every year
  • Occur in 10-15% of Patients Prior to the Development of Stroke

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Vascular Anatomy

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Clinical Presentations

  • Weakness: Face, Arm, Leg
  • Sensory Loss :Face, Arm, Leg
  • Vision Loss in one Eye
  • Trouble speaking or understanding
  • Vertigo, Double Vision

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Pathogenesis of TIA

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  • Cardiac source: Atrial fibrillation, Cardiac thrombus
  • Carotid Artery Stenosis
  • Hypercoagulability
  • Hypertension

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Risk Factors for TIA

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  1. Age > 55
  2. Male > Female
  3. Family History for TIA
  4. Hypertension
  5. Hyperlipidemia
  6. Smoking, Alcohol
  7. Diabetes
  8. Internal Carotid stenosis
  9. Atrial fibrillation
  10. Obesity
  11. Blood Clots

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Risk of stroke after TIA

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  • TIA is a serious warning for impending Ischemic stroke
  • The Risk is highest within the first 48 hours following TIA
  • 10-15%: Stroke within 90 Days
  • Half of above strokes within the first 48 Hours of TIA

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  • Differential Diagnosis:
  • TIA mimics

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Differential Diagnosis: TIA mimics

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  • Hypoglycemia
  • Seizures: Shorter, Seizure activity: Todds Paralysis
  • Migraine: slow Progression and Headache, other symptoms
  • Syncope: Faint
  • Brain Tumors: Gradual onset
  • Intracranial bleeding

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Evaluation�

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  • To be Done Urgently?

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Why to be done Urgently?�

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  • To Decrease Risk of Subsequent Stroke

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Evaluation�

Laboratory�

  • CBC
  • Blood Chemistry: Glucose
  • Lipid Panel
  • Coagulation studies

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Imaging�

  • ECG
  • Tele monitoring
  • CXR
  • Carotid Doppler or CTA of Neck
  • MRI Brain w/o contrast
  • Echocardiogram: TTE, TEE

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Management

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  • Antiplatelet (dec stroke by 25%)
  • Statin
  • Risk Factor Control:

>Hypertension: Reduce stroke by 40%

>Diabetes

>Diet

>Exercise

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Treat Underlying Cause

  • Anticoagulants: A fib, Thrombus
  • Carotid endarterectomy: >50% Stenosis

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  • This reduce risk of recurrent stroke or future TIA by at least 75%

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We Made the Diagnosis of TIA

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What Is Next?

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What Is Next?

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Hospital Admission Versus Discharge Home???

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Risk of Stroke After TIA

Identification of risk factors that predict stroke after TIA is important in the assessment of patients presenting with TIA.

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The ABCD2 score provides and evaluation of this risk.

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Points are Given for the following risk factors.

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ABCD2 Scoring System

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Age

≥ 60 years

1 Point

Blood Pressure

≥140 and or ≥ 90 mm Hg

1 Point

Clinical Symptoms

Speech impairment/No weakness

Focal Weakness

1 Point

2 Points

Duration of Symptoms

10-59 minutes

≥ 60 minutes

1 Point

2 Points

Diabetes

Yes

1 Point

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Based on the Score: �The 2 Day Risk of Stroke is

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ABCD2 Score

Risk of Stroke

0-1

0 %

2-3

1.3 %

4-5

4.1%

6-7

8.1%

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Hospitalize Patients with TIA if Present within 72 hours of symptoms

 

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  • ABCD2 score of ≥3

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  • ABCD2 score of 0 to 2 if we can't get work up as outpatient in 2 Days

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Case Study

A 65 years old male with history of Diabetes present with Sudden onset of word finding difficulty associated with right face, right upper extremity weakness, symptoms lasted for 20 minutes then resolved completely, blood Pressure in the clinic was 145/85, Patient was diagnosed with TIA.

According to the ABCD2 score, which of the following is not used as a predictor of occurrence of a stroke?

  1. Diabetes
  2. Age of 60 years or more
  3. Hypertension
  4. Duration of neurologic symptoms
  5. Hyperlipidemia

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What is the ABCD2 Score?

  1. 3
  2. 4
  3. 5
  4. 6

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What is Next?

  1. Transfer to the Hospital for Admission?
  2. Discharge Home and outpatient work up?

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References�

  1.  Albers GW, Caplan LR, Easton JD, Fayad PB, Mohr JP, Saver JL, Sherman DG, for the TIA Working Group. Transient ischemic attack: proposal for a new definition. N Engl J Med. 2002; 347: 1713–1716.
  2. https://pubmed.ncbi.nlm.nih.gov/
  3. https://www.stroke.org/
  4. https://www.aan.com/
  5. https://www.heart.org/
  6. https://www.ahajournals.org/journal/str

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