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TIA in the ED

Case:

A 54-year-old male presents to the Emergency Department 4 hours after an hour-long episode of slurred speech and confusion that has since resolved. He works in landscaping outdoors and ascribes his symptoms to the heat and dehydration. He denies experiencing such symptoms in the past. He has HTN for which he takes lisinopril, though admits to missing doses recently. Initial labs are within normal ranges and a non-contrast CT head/brain is negative for any intracranial processes. Vital signs include a blood pressure of 170/100 with all other vitals within normal limits. Physical exam with a detailed neurologic component reveals no abnormalities. The patient is AAOx4 with a GCS of 15. He is asymptomatic, sitting comfortably in the bed, and wants to get home to his wife.

Clinical Question:

What is the appropriate course of action for the patient at this time?

Background:

TIA is a self-limited episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction (1). TIA has been compared to a ‘minor stroke’ but should be differentiated from a stroke (CVA) on the basis of its lack of persisting neurological deficit. Signs and Symptoms of TIA are identical to those of CVA:

  • Weakness or loss of motor control on one side of body, face, or limb

  • Numbness or paresthesia

  • Changes or loss in vision

  • Slurred speech

  • Aphasia

Risk Factors for TIA & CVA (3)

  • Prior history of Stroke

  • Coronary Artery Disease

  • Hypertension

  • Tobacco use

  • Obesity

  • Diabetes

  • Hyperlipidemia

Diagnostic Tests – ED

CT head/brain without contrast- rule out bleed, mass, etc.

Blood panels- rule out metabolic abnormalities

EKG- evaluate for cardiac arrhythmias like atrial fibrillation

Inpatient/Outpatient Workup

Goal is identification of modifiable risk factors in order to prevent future stroke:

  • Lipid panel

  • Echocardiogram- assess for structural or functional heart abnormalities

  • Carotid Ultrasound/CTA - assess for vascular atherosclerosis

  • MRI/MRA – evaluate for CVA and vascular stenoses

Summary of Evidence

In a study of 356 patients diagnosed with an acute ischemic stroke: MRI revealed evidence of stroke in 156 patients (46%) 3 hours after onset while CT revealed evidence of stroke in just 35 patients (10%) in the same time frame. (4) Evaluation and management of TIAs is crucial to best prevent future cerebrovascular events as these patients face higher risks of CVA after an initial TIA. A study of 1707 patients presenting to the ED with a TIA found that 11% had a recurrent TIA and 10% had a subsequent stroke (CVA) within the next 90 days. (5) Studies show prompt assessment to be a prognostic factor in long term outcomes (6) Clinical outcomes and long-term prognosis may potentially depend on a physician’s course of initial management TIA.

Recommendations

  • Duration of neurological symptoms does not correlate accurately with the risk of future events (1). Shorter symptomatic periods may still lead to serious future outcomes

  • Encourage patients to seek care at the onset of symptoms rather than waiting to assess for symptom resolution. (6)

  • A thorough physical exam and neurological assessment is vital to the appropriate management of each patient

  • Consider social and risk factors to best determine which patients may benefit from admission compared to those who may be observed or discharged with plan for close follow up

  • Disposition should be individualized based on the patient presentation and the physician’s clinical gestalt.There are no definitive studies concluding on the best course of management or disposition for patients with TIA.

References:

  1. Definition, etiology, and clinical manifestations of transient ischemic attack. Karen L. Furie, Hakan Ay. 2017, May. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/definition-etiology-and-clinical-manifestations-of-transient-ischemic-attack?source=bookmarks_widget#H53896871

  2. Initial evaluation and management of transient ischemic attack and minor ischemic stroke. Karen L. Furie, Hakan Ay. 2017, May. UpToDate. Waltham, MA: UpToDate Inc.

  3. Transient ischemic attack: Part II. Risk factor modification and treatment. B. Brent Simmons, Annette B. Gadegbeku, Barbara Cirignano. Am Fam Physician. 2012 Sep 15; 86(6): 527–532.

  4. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Chalela JA, Kidwell CS, Nentwich LM, et al. Lancet. 2007;369(9558):293-298. doi:10.1016/S0140-6736(07)60151-2.

  5. A comparison of risk factors for recurrent TIA and stroke in patients diagnosed with TIAs. Claiborne Johnston, Steve Sidney, Allan L. Bernstein, Daryl R. Gress Neurology. 2003 Jan 28; 60(2): 280–285.

  6. National Stroke Association guidelines for the management of transient ischemic attacks.S. Claiborne Johnston, Mai N. Nguyen-Huynh, Miriam E. Schwarz, Kate Fuller, Christina E. Williams, S. Andrew Josephson, Graeme J. Hankey, Robert G. Hart, Steven R. Levine, Jose Biller, et al.Ann Neurol. 2006 Sep; 60(3): 301–313. doi: 10.1002/ana.2094.

 

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